- Purpose of Job
- Responsible for billing, electronic claims submission, follow up and collections of patient accounts.
- Job Requirements
- High school diploma, General Educational Development (GED) or equivalent required
- Coursework in Coding, Billing or Healthcare Management normally acquired through enrollment in a secondary education institution or online classes through the American Heath Information Management Association (AHIMA) preferred.
- Demonstration of knowledge and practice in medical terminology, third party payer appeals, denial trending and analysis, ICD-9, ICD-10, CPT4/HCPCS Coding, UB04 and CMS1500 claim data as supported by the Patient Billing Rep Skill Set Examination required.
- Minimum of 1-2 years experience in a healthcare business office setting operating patient accounting software, electronic billing software and/or accessing payer websites required.
- Prior experience interpreting contractual language preferred.
- Ability to create and submit both original and corrected claims.
- Skill in interpreting UB04 and/or CMS1500 claim data to be able to troubleshoot claim edits and resolve payer billing requirements both timely and accurately.
- Ability to audit accounts and payer explanation of benefits (EOBs) to determine appropriate action.
- Ability to maintain a working knowledge of multiple system applications.
- Ability to use effective communication skills in order to handle patient inquires, attorneys, health system staff and payers on a professional level.
- Knowledge and understanding of accounting and business principles to enable accurate auditing of patient accounts.
- Ability to follow up with the 3rd party payers for claims and appeals submitted to ensure timely and accurate processing.
- Ability to review and clearly articulate denial trends and patterns to identify potential opportunity to prevent denials and maximize reimbursement.
- Physical Requirements
- Weight Demands
- Light Work - Exerting up to 20 pounds of force.
- Occasionally Performed (1%-33%):
- Distinguish colors
- Frequently Performed (34%-66%):
- Repetitive Motions
- Constantly Performed (67%-100%):
- Not Related:
- Biological agents (primary air born and blood born viruses) (Jobs with Patient contact) (BBF)
- Physical hazards (noise, temperature, lighting, wet floors, outdoors, sharps) (more than ordinary office environment)
- Explosives (pressurized gas)
- Electrical Shock/Static
- Radiation Alpha, Beta and Gamma (particles such as X-ray, Cat Scan, Gamma Knife, etc)
- Radiation Non-Ionizing (Ultraviolet, visible light, infrared and microwaves that causes injuries to tissue or thermal or photochemical means)
- Rare (1-33%):
- Chemical agents (Toxic, Corrosive, Flammable, Latex)
- Mechanical moving parts/vibrations
- Note: Safety Officer can assist with identification of job hazards
- Essential Job Functions
- Essential Functions I
UB04/837I and CMS1500/837P Claim Edit Handling/Billing/Interpretation
- All EDI and paper claims submitted are to be billed as needed following department and payer specific guidelines.
- Obtains appropriate EOB's through use of health system resources.
- Reviews Billing Scrubber Claim Detail Screens to ensure data is appropriate for claim submission.
- Ensure that claim corrections identified in billing scrubber are appropriately updated and documented in Source System.
- Prepares secondary and tertiary billings, manually and electronically on UB04's and/or 1500's for accurate reimbursement.
- Submits adjusted UB04/837I and/or CMS1500/837P claims according to department and payer specific guidelines.
Display Effective Communication Skills
- Demonstrates active listening skills.
- Notifies and keeps supervisor informed on denial and any other trends identified.
- Follows telephone etiquette procedures set forth by the organization and/or individual department.
- Professional/Courteous responses when communicating with customers, health system staff and management.
- Can effectively communicate in meetings/forums to a large or medium group of individuals.
- Works with supervisor to streamline process and decrease inefficiencies.
Handling of Referrals
- Timely and accurately handling of referrals, both regular and escalated priority from management, within department guidelines.
- Documents clearly and appropriately all referrals (including patient inquiries) in the Source System when necessary.
- If necessary, follows up with patients on final results of inquiry both timely and professionally. Notifies patient of final results of account handling in question.
Knowledge of System Applications
- Demonstrates ability to learn and maintain a working knowledge on all the current health system applications.
- Identify/obtain/print medical records as necessary for resolution of denial or system edits according to department guidelines.
- Assists with testing and roll out plans to introduce new functionality within system applications used by the department.
Auditing of Patient Accounts
- Understand accounting and business principles to accurately determine the remaining balance on a given encounter.
- Upon accurately auditing encounter or visit, is able to understand and update proration to make sure dollars are allocated to the appropriate benefit orders if needed.
- Leverages all needed resources to complete an audit of an account.
- Documents audit finding and actions taken in Source System when necessary.
Claim/Appeal Follow Up with Third Party Payers
- Full understanding of all necessary third party payer appeals, billing and follow up guidelines including specific time frames and possible form filing requirements.
- Leverages payer websites, automated tools and contract resources to streamline the follow up process.
- Appropriate documentation in Source System when necessary.
- Ability to interpret all appeal and follow up correspondence for accurate handling.
Denial Trending and Analysis
- Can clearly identify, trend and articulate patterns and issues from provided denials data.
- Can clearly provide alternative solutions with regards to denial findings.
- Leverage all necessary denial data sources as needed for trending and analysis.
- Leverage all necessary contract manager data sources and payer contracts as needed for reimbursement analysis.
- Has the ability to effectively network and communicate with outside department, payers, patients and any other necessary resources to resolve denial issues timely.
- Able to identify and correct transaction codes for proper write off classification.
- Accurate usage of transaction codes for efficient organizational reporting.
- Posts transactions within the departmental thresholds.
Special Projects and Tasks as Assigned
- Completion of any assigned projects timely, accurately and to the specifications of leadership.
- Ability to articulate and communicate trend or other findings to various leadership personnel within the organization.
- Ensure Daily/Weekly/Monthly assignments are handled accurately and timely.
Maintaining Daily Workflow
- Manages and maintains assigned workflow queues according to department guidelines.
- Follow appropriate policies and procedures with regards to handling of denials and all other assigned queues.
- Mail/Correspondence processed and handled following departmental guidelines.
- Documents both timely and appropriately in Source System using proper documentation methods.
- Fundamental understanding of different work item, state based and exception queues within the Patient Accounting System applications.
Essential Functions II
Participates in mandatory in-services and/or CE programs as mandated by policies and procedures/external agencies and as directed by management.
Follows and understands the mission, vision, core values, Employee Standards of Behavior and company policies/procedures.
Other duties as assigned.