SUMMARY:

May perform the following based on job role as defined under essential functions.  Performs Medicare billing and follow up, commercial and state Medicaid appeals, preparation for state Medicaid state fair hearings. Prepares refunds for payers and patient accounts which includes a complex review and reconciliation of government and non-government payers. Resolves problematic accounts demonstrating complete understanding of payer contracts and or payer requirements to ensure timely and accurate payments or timely responses on credits, recoupments, and refund requests. May be responsible for balancing all cash receipts and daily/monthly workbook with the finance department. (job specific).  Makes independent decisions based on payer guidelines for reconciling, billing and or credit balances on accounts.

 

ESSENTIAL FUNCTIONS:

Exhibits excellence in customer service through appropriate attitude and interaction with all patients, visitors and staff. 

Adheres to and supports team members in exhibiting TMCH values of integrity, community, compassion, and dedication. 

Assists management in maintaining or reducing account receivable (AR) days to meet industry standards and improve organizational cash flows.

Ensures patient accounts are refunded and/or billed in a timely, complete, and accurate manner in accordance with payer contracts and payer guidelines, and/or billing and follow-up guidelines (depends on review and reconciliation process).

Prepares and enters contractual write-offs and dispute letters to Medicare or insurance carriers as required.

Serves as information resource to patients and hospital staff regarding credit and collection policies or Medicare polices and benefits.

Provides routine daily internal and external interface with unit/department management and staff, other service areas, information systems, physicians, physicians’ office staff, patients, software/hardware vendors, and third party payers  in order to resolve patient disputes, and/or patient credits, and/or audits, and/or patient concerns,  and/or billing audits.

Analyzes and prepares commercial/Medicaid payer claim denial reconsiderations and or formal disputes as needed on non clinical denials based on payer guidelines.

Follows up on all appealed claims assigned, escalating as needed based on appeal levels with the payer.

Maintains online payer resource reference library related to payer policies utilized for follow up and or appeals.

Reviews/analyzes payer driven denial reason codes to determine root cause of the denial. Submits recommendations to Management on any identified trends in order to assist in reducing denials.

Assists with problem solving, inquiries, and customer interaction to ensure positive results.

Trains and assists in the implementation of new software programs/systems and related technologies.

Adheres to TMCH organizational and department-specific safety and confidentiality policies and standards.

Performs related duties as assigned.

 

 

Medicare Billing Specialist: Performs complex review and reconciliation of Medicare patient accounts.  Communicates with Medicare regulatory or, state agencies, related to Medicare billing, collection or refund activities.  Works independently to resolve problems and demonstrates complete understanding of payer requirements to ensure timely and accurate payment.  Completes reconciliation and billing of accounts making independent decisions based on situations.  Works directly with Finance Director on any Medicare payment discrepancies and works directly with Compliance on CMS Regulatory requirements.  Additionally, works with Health Information Management (HIM) on coding issue and local coverage determination (LCD) issues.  Experience:  Five (5) years of related experience such as medical billing, collections or customer service, preferably in an acute care setting.

MINIMUM QUALIFICATIONS

EDUCATION:  High School diploma or General Education Degree (GED); or an equivalent combination of relevant education and experience.

EXPERIENCE: Varies based on position, see above.

LICENSURE OR CERTIFICATION: None required.

KNOWLEDGE, SKILLS AND ABILITIES:

·         Knowledge of medical insurance practices and policies and regulations (Medicare Billing Specialist and State Fair Hearing/Advanced Billing Specialist only).

·         Knowledge of government and non-government uniform billing guidelines (Medicare Billing Specialist and State Fair Hearing/Advanced Billing Specialist only).

·         Skills in critical thinking based on the review of credits applied to the patients accounts (Refund Specialist only).

·         Strong working knowledge of medical terminology and coding related to hospital billing and/or professional billing such as revenue codes, CPT codes, diagnosis codes, modifiers, occurrence codes, and value codes and the appropriate use.

·         Skill in evaluating bills/claims with an understanding of the types of facilities patients are coming from and/or going to for accurate billing in order to collect payment in a timely manner.

·         Skills in Preparing reconsiderations, formal disputes for assigned nonclinical related denials.

·         Strong verbal and written analytical skills to prepare formal claim appeals.

·         Possesses and maintains knowledge of current Medicare/CMS regulatory and third party payer requirements to support billing reimbursement.

·         Keeps self-up to date on local coverage and national coverage determinations (Medicare Billing Specialist only)

·         Keeps self-up to date on any up and coming Medicare changes or updates by dialing into monthly/ quarterly ask the contractor and other Medicare forums as well as information on changes available on the Medicare website (Medicare Billing Specialist only).

·         Possesses a clear understanding of and ability to work directly with the nurse auditor on ADR’s, Suspense claims, T status claims, Probes, Cert’s, and Appeal processes (Medicare Billing Specialist and State Fair Hearing/Advanced Billing Specialist only).

·         Knowledge of the Medicare credit balance analysis and reporting (Medicare Billing Specialist only).

·         Prepares disputes, redeterminations and reconsiderations for Medicare denied claims in conjunction with nurse auditor (Medicare Billing Specialist only).

·         Strong skills in the use of computer applications and systems including:  Excel, Word, Internet, email, and miscellaneous programs and networked computer systems.

·         Ability to read and comprehend instructions, short correspondence, and memos.

·         Exceptional communication skills, with the ability to write correspondence and effectively present information in one-on-one and small groups situations to customers, clients, and other employees of the organization.

·         Ability to read and interpret documents such as safety rules, procedure manuals, and governmental regulations. 

·         Ability to effectively present information and respond to inquiries or complaints from payers, patients and/or their representatives, and the general public.

·         Strong analytical skills in order to take appropriate action on Medicare claims, reports, spreadsheets and correspondence (Medicare Billing Specialist only).

·         Ability to calculate figures and compute rate, ratio, and percent and to draw and interpret bar graphs; ability to apply basic algebraic concepts.

·         Ability to apply common senses understanding to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.