Job Description
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.
Refund Specialist: Performs a complex review and reconciliation of credit balances on patient accounts. Communicates with insurance companies, state agencies AHCCCS/Medicaid and patient related to refund activities. Works independently to resolve account problems and has a complete understanding of the payer contracts to ensure accuracy and timely response on credits, recoupments and refund requests. Primary contact for all insurance credits. Completes review of the credit balance accounts making independent decisions on every situation. Maintains and fosters effective public relations with patients and public while negotiating payment plans with patients as authorized. Experience: Five (5) years of related experience such as medical billing, collections or customer service, preferably in an acute care setting.
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.
State Fair Hearing/Advanced Billing Specialist: Analyzes all Arizona Medicaid notices of decisions for potential state fair hearings. Prepares all exhibits, files all State fair hearing motions, prepares opening statement documents and actively participates in state fair hearings. Works directly with nurse auditor, Nurse Case Manager, HIM gathering all clinical data documents and or any applicable state statutes pertaining to clinical cases. Monitors results of all state fair hearing cases. Analyzes, prepares and files internal claim disputes. Works independently to resolve problems and demonstrates complete understanding of payer requirements to ensure timely and accurate payments. Analyzes and completes various internal and external reports and spreadsheets. Assists with billing as needed. Assists with training as needed. Other duties as assigned. Experience: Five (5) years of related experience such as medical billing, collections, preferably in an acute care setting.
Cash Specialist: Performs complex review of every type of an account with cash posting issues. This position is the main contact for the entire department with cash and adjustment issues. Communicates with insurance companies, state agencies AHCCCS/Medicaid and patient related to refund activities. Works independently to resolve account problems and has a complete understanding of the payer contracts to ensure accuracy and timely response on credits, recoupments and refund requests. Manages and balances the daily workbook. Works with all department Managers for any cash discrepancies on a daily basis. Responsible for balancing the workbook for month end and the finance department. Experience: Five (5) years of related experience such as medical billing, collections or customer service, preferably in an acute care setting.
Customer Service: Performs complex review and reconciliation of self-pay, bankruptcy, and lien accounts. Communicates with insurance companies, state agencies AHCCCS/Medicaid to verify coverage and benefits. Works independently to resolve account problems and has a complete understanding of the payer contracts to ensure accuracy and timely response on patient concerns. Main point of contact for the Customer Service and Self Pay Collectors teams for escalated patient calls. Department liaison with our third-party liability vendors. Collaborates with Human Resources to monitor and resolve employee contract debts. Works with Health Information Management (HIM) for third party liability billing requests. Maintains and fosters effective public relations with patients and public while negotiating payments plans with patients as authorized. Analyzes and completes various internal reports and spreadsheets. Assists with training as needed. Other duties as assigned. Experience: Five (5) years of related experience such as medical billing, collections, or customer service. Preferably in an acute care setting.
Denial Specialist: Performs complex reviews and reconciliation of non-clinical denied commercial and Medicaid claims. Communicates with insurance companies and issues related to claim denials. Files corrected claims or levels of appeals as appropriate. Works independently to resolve problems and demonstrates complete understanding of payer requirements related to disputes/appeals on denied claims. Will assist in developing and maintaining standardized processes related to individual payer requirements. Assists in identifying denial root causes and communicates resolution to Management to correct any denial trends. Experience: Five (5) years of related experience in 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 ADRs, Suspense claims, T status claims, Probes, Certs, 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.