Billing and Collections Specialist, RMF Denials Management

FLSA STATUS: ☐ Exempt ☒ Non-Exempt MISSION STATEMENT: Our Mission is to improve the well-being of those we serve with a commitment to excellence: every patient, every encounter, every time. VISION: Our Vision is to create a world-class health system to advance medicine and increase access for the communities we serve by empowering caregivers to heal through compassion, knowledge, innovation, integrated care and excellence.

The Billing and Collections Specialist in the RMF Denials Management department is responsible for conducting quality assurance reviews on denied claims. When an appeal is necessary, the specialist drafts the appeal to payers using relevant clinical indicators, official coding guidelines, and documentation from the patient’s medical record. Basic knowledge of medical terminology, CPT/HCPCS codes and ICD10 codes.

Additionally, the specialist plays a crucial role in reporting quality results, tracking and identifying educational opportunities within the Revenue Cycle departments, addressing client subject matter needs, and contributing to educational support and training efforts. POSITION EDUCATION/

• High School Diploma/GED is required 0-2 years of experience in denial management, utilization review or prior authorization in a hospital, provider, or healthcare system. Experience in healthcare billing and reimbursement Experience with EMR system workflows Strong knowledge of health care services reimbursement methodologies Knowledge of claim forms and remittance advice, including coding and billing practices Ability to interpret contract language Working knowledge of medical terminology Knowledge of Microsoft Office Suite Excellent Customer Service Bilingual- English/Spanish, preferred Previous healthcare and hospital/professional experience preferred. Ability to use the internet to obtain information from Third Party Payers or other sources is required. Requires working with minimal to moderate interruptions JOB KNOWLEDGE/EXPERIENCE: Previous healthcare and hospital/professional experience preferred.
• Communicates clearly and concisely and is able to work effectively with other employees, patients and external parties
• Establishes and maintains long-term customer relationships, building rapport with other department staff
• Demonstrates proficiency in Microsoft Office applications, be able to type at least 35 WPM, and good working knowledge of Excel is required.
• Able to perform basic mathematical calculations, balance and reconcile figures, punctuate properly and spell correctly.
• Medical Terminology, ICD – 10, Codes, CPT Codes, HCPCS code, Modifier knowledge required. Ability to use the internet to obtain information from Third Party Payers or other sources is required. Requires working with minimal to moderate interruptions
• Occasional evening or weekend work may be required

• Promote Facility Mission: Advocate for the facility’s mission, vision, and values by effectively communicating them and incorporating them into service development, standards, and practices.
• Denials and Appeals Proficiency: Demonstrate expertise in handling denials and appeals.
• Create Appeal Letters: Draft detailed appeal letters with all necessary information.
• Follow-Up on Insurance Accounts: Manage and follow up on assigned insurance accounts
• Adhere to Billing Guidelines: Follow governmental billing and collection rules as outlined in Medicare/Medicaid manuals when interacting with insurance carriers.
• Software Proficiency: Utilize different software systems to verify eligibility and claim status
• Billing and Follow-Up: Demonstrate proficiency in billing and following up on claims using online or billing software.
• Payer Website Access: Access payer websites as needed to retrieve information.
• Managed Care Contract Knowledge: Understand managed care contract terms to determine correct reimbursement levels.
• Reimbursement Comparison: Compare payer reimbursement to expected payments and address discrepancies with insurance carriers.
• Patient Contact: Contact patients to gather additional information for insurance purposes, if needed.
• Fax and Message Follow-Up: Address faxes or messages from carriers within 24 hours to ensure timely and compliant resolution of denials.
• Account Follow-Up: Follow up on assigned Accounts Receivable trackers or custom reports, contacting insurance carriers for payment or recoupments.
• Notes: Enter appropriate notes in host system
• Correspondence Response: Respond to insurance carrier correspondence in a timely manner.
• Insurance Billing: Identify accounts needing insurance billing/ rebilling or appeal
• Appeal Management: Enter and maintain appealed accounts using appropriate indicators in host system
• Compliance Notification: Notify management of any compliance concerns or incidents.
• HIPAA Compliance: Ensure patient confidentiality is maintained in accordance with HIPAA policies and procedures.
• Educational Participation: Attend educational conference calls and complete HealthStream learning modules on time.
• Productivity and Quality: Maintain required productivity and quality standards, and adhere to QA process requirements.
• Cross-Training: Work towards cross-training and familiarizing oneself with both professional and facility denials.
• Other duties as assigned. LINES OF REPSONSIBILITIES: (Chain-of-command) Billing and Collections Supervisor → 2. Billing and Collections Manager → 3. VP of Revenue Cycle → 4. Chief Revenue Officer Other information: CUSTOMER SERVICE: Provide excellent customer service to all DHR customers. All employees are required to attend the DHR C.A.R.E.S program which outlines the Customer Service Principals including: Commitment, Accountability, Respect, Excellence and Service. AGE SPECIFIC: Employees must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served in his/her assigned unit. The individual must demonstrate knowledge of principles of growth and development over the life span and possess the ability to assess data reflective of the patient’s status and interpret the appropriate information needed to identify each patient’s requirement relative to his or her age. AMERICANS WITH DISABILITIES ACT: (ADA): A.

Indicated by bold print within performance standards, preceding individual numbered criteria. The following table provides physical requirements that will be associated with, but not limited to, this position: Light/moderate lifting up to 20 lbs., from the floor to shoulder height. Yes Kneeling Yes Must be able to assist other employees with lifting more than 20 lbs.

Yes Walking Yes Light/moderate carrying up to 20 lbs. Yes Standing/Squatting Yes Straight pulling Yes Sitting Yes Pulling hand over hand Yes Pushing Yes Repeated bending Yes Stooping/Bending Yes Reaching above shoulder Yes Climbing Stairs Yes Simple grasping Yes Climbing Ladders No Dual simultaneous grasping Yes Depth Perceptions needed Yes Ability to see Yes Identify Colors Yes Operating office equipment Yes Twisting Yes Operating mechanical equipment Yes Crawling No Ability to read and write Yes Ability to Count Yes Ability to hear verbal communication without aid Yes Operating Personal Vehicle Yes Ability to comprehend written/verbal communication Yes Other: Ability to deal with stress Yes OSHA Category III B.

Working Conditions: The individual spends over 95% of his/her time in an air-conditioned environment with varying exposures to noise. There is protection from weather conditions but not necessarily from temperature changes. The position does have low exposure to malodorous, infectious body fluids from patients and some minimal exposure to noxious smells from cleansing agents.

C. Occupational Exposure: This position has minimal to no exposure to blood, body fluids, or tissues and is an OSHA Category III (although situations can be imagined or hypothesized under which anyone, anywhere, might encounter potential exposure to body fluids). Person who performs these duties are not called upon as part of their employment to perform or assist in emergency medical care or first aid or to be potentially exposed in some other way.

D. Aptitudes: HIGH 1 2 3 4 5 6 LOW Intelligence: General learning ability: The ability to “catch on” or understand instructions and underlying principles. Ability to reason and make judgments. 3 Verbal: Ability to understand meanings of words and ideas associated with them, and to use them effectively.

To comprehend language, to understand relationships between words, and to understand meanings of whole sentences and paragraphs. To present information or ideas clearly. 3 Numerical: Ability to perform arithmetic operations quickly and accurately. 2 Spatial: Ability to comprehend forms in space and understands relationships of plane and solid objects. Frequently described as the ability to “visualize” objects or two or three dimensions, or to think visually of geometric forms. 2 Form Perception: Ability to perceive pertinent details and objects or in pictorial or graphic material to make visual comparisons and discriminations and see slight differences in shapes and shadings of figures and widths and lengths of lines. 3 Clerical Perception: Ability to receive pertinent details and verbal or tabular material.

To observe differences in copy, to proofread words and numbers, and to avoid perceptual errors in arithmetic computation. 2 Motor Coordination: Ability to coordinate eyes and hands to fingers rapidly and accurately in making precise movements with speed. Ability to make a movement response accurately and quickly. 3 Finger Dexterity: Ability to move hands easily and skillfully. To work with fingers in placing and turning motions. 3 Manual Dexterity: Ability to move hands easily and skillfully.

To work with hands in placing and turning motions. 3 Eye-Hand-Foot Coordination: Ability to move the hand and foot coordinately with each other in accordance with visual stimuli. 3 Color Discrimination: Ability to perceive and respond to similarities or differences in colors, shapes, or other values of the same or different color. To identify a particular color, or to recognize harmonious or contrasting color combinations, or to match color adequately. 3 I have read and reviewed my job description with my supervisor or designee and I understand the job I am expected to perform.

If applicable ____________ certification will be completed within _________ time frame of hire/transfer date. Employee Signature: ________________________________ Date: ____________________ Transfer/Hire Date Effective: ________________________.