Description

• Purpose of Job
  • Responsible for billing, electronic claims submission, follow up and collections of patient accounts.
• Job Requirements
  • Education
    • 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.
  • 
    Experience
    • 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.
  • 
    License/Certifications
    • N/A
  • 
    Skills/Knowledge/Abilities
    • 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.
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    Physical Activity
    • Occasionally Performed (1%-33%):
      • Balancing
      • Climbing
      • Carrying
      • Crawling
      • Crouching
      • Distinguish colors
      • Kneeling
      • Lifting
      • Pulling/Pushing
      • Reaching
      • Standing
      • Stooping/bending
      • Twisting
      • Walking
    • Frequently Performed (34%-66%):
      • Hearing
      • Repetitive Motions
      • Seeing/Visual
      • Speaking/talking
    • Constantly Performed (67%-100%):
      • Fingering/Touching
      • Grasping
      • Keyboarding/typing
      • Sitting
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    Job Hazards
    • 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)
      • Equipment/Machinery/Tools
      • 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
     

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      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.

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      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.

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      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.

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      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.

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      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.

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      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.

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      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.

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      Transaction Review/Posting
      • 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.

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      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.

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      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
     

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      Participates in mandatory in-services and/or CE programs as mandated by policies and procedures/external agencies and as directed by management.

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      Follows and understands the mission, vision, core values, Employee Standards of Behavior and company policies/procedures.

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      Other duties as assigned.