The Medicare Billing and Follow-up Representative are responsible for the compliant, accurate and timely billing and follow-up of all hospital Medicare and Medicare Advantage Patient Accounts.
and Responsibilities Duties and responsibilities described represent the general tasks performed on a daily basis, but not limited as other tasks may be assigned. Submit Medicare/Medicare Advantage plan claims both electronic and paper claims (UB-04 and 1500) to the appropriate government and non-government payers. Submit shadow bill (Information only claims) to Medicare.
Understand how to resolve Medicare/Medicare MA billing edits and/or warnings and billing edits that are identified in the Patient Accounting Billing System. Knowledge of working F. I.
S. S. (Florida Institutional Shared System) in order to resolve Medicare claim issues.
Keep abreast of Medicare/Medicare MA government requirements and regulations. Understand ABN’s and the requirements when and how to appropriately bill claims for resolution. Experience and knowledge with working the Medicare Quarterly Credit balance report.
Experience in ICD-10, CPT-4 and HCPC professional terminology. Knowledge and understanding regarding the processing of the In-Patient lifetime reserved notifications, rules and regulations. Knowledge and understanding working MSP (Medicare Secondary Payer) files.
Knowledge and understanding billing TPL (Third Party Liability) claims and conditional billing. Current knowledge of Medicare Transmittal, Change Requests and the ability to understand and interpret Monthly CMS News Updates. Understands LCD (Local Coverage Determination) and NCD (National Coverage Determination) and how it relates to medical necessity.
Ability to navigate and fully utilize Medicare Fiscal Intermediary (Palmetto GBA) and CMS web sites. Understanding of the CMS Publication: 100-4 (Medicare Claims Processing Manual). Ensures claim information is complete and accurate in order to maximize the clean claim rate resulting in claim resolution and payment for complex billing and payment issues.
Analyze information contained within the Patient Accounting and Billing system to make decisions on how to proceed with the billing of an. Processes rejections by correcting any billing error and resubmitting claims to government and non-government payers. Place unbillable claims on hold and properly communicate to various Hospital departments the information needed to accurately.
Process late charge claims in the event that charges are not entered in a timely fashion by Hospital Departments. Submit corrected claims in the event that the original claim information has changed for various reasons. Perform the billing of complex scenarios such as interim, self-audit, combined, and split billing etc.
Limit the number of unreleased claims by reviewing all imported claims and either billing or holding the claim for further review. Meet Billing and Follow-up productivity and quality requirements as developed by Leadership. Measured on high production levels, quality of work output, in compliance with established CRH's policy and standards.
Review patient financial records and/or claims prior to submission to ensure payer-specific requirements are met. Keep abreast of payer-specific and government requirements and regulations. Follow up on unprocessed or unpaid claims until a claims resolution is achieved.
Generates letters to insurance or patients as needed in order to resolve unpaid claim. Works on and maintains spreadsheets by sorting/adding pertinent data. Analyze information contained within the billing systems to make decisions on how to proceed with the.
Work independently and has the ability to make decisions relative to individual work activities. Identify comments in the billing systems by using initials and using approved abbreviations for universal understanding. Keep documentation clear, concise, and to the point, while including enough information for a clear understanding of the work performed and actions needed.
Create appropriate documentation, correspondence, emails, etc. and ensure that they are scanned to the proper account for accurate documentation. Read, understand, and explain benefits from all payers to coworkers, physicians, and patients. Make phone calls, use the internet, and send mail to payers for follow-up on unprocessed claims, incorrectly processed claims, or claims in question.
Develop relationships with customers/patients/co-workers in order to gather and process information or resolve issues in order to receive accurate reimbursement and optimize internal and external customer satisfaction. Post accurate adjustments as appropriate per billing policies and procedures, payer explanation of benefits, and the management directive. Maintain work procedures pertinent to the job assignment.
Accountable for individual work activities. Resolve questions that arise regarding correct charging and/or other concerns regarding services provided. Complete cross-training, as deemed necessary by management, to ensure efficient department operations.
Report potential or identified problems with systems, payers, and processes to the manager in a timely manner. Complete special project assignments in a timely fashion. Follows HIPAA guidelines in order to maintain strict confidentiality of all patient financial and hospital information at all.
Perform other duties as assigned. Analysis, identification of trends, validation, and compliance as related to revenue cycle activities, generating additional revenue to include denials management. Perform a deep dive quality review of account worked for all billers and follow-up staff.
Ensure effective and efficient work flow of the department and assist with individual workflow design. Troubleshoots; follows through and resolves issues related to the patient revenue cycle, develops and presents recommendations for further consideration by management. Keep abreast of updates, rules, requirements and regulations for all government payers.
Demonstrate knowledge of contract terms for multiple insurance carriers. Assignments defined by management as special projects/analysis to be completed in a timely manner. Submit electronic and paper claims to appropriate insurance payers as directed.
Follow up in a timely manner on unprocessed, unpaid and/or denied claims until resolution is reached by working work queues. Make phone calls, use the internet, or send emails per payer specifications to follow up on claims in question. Enter and analyze information in billing system to record action in clear concise manner.
Ensure that all documentation is clear, concise, and to the point, but contains enough information for understanding of work performed and actions needed. Ensure that the appropriate documentation, correspondence, emails, etc. are scanned into accounts for accurate documentation of work performed and status of the account. Research credit balances to resolve accounts when needed.
Understand and use the department computer systems: MPF, Epic HB, OnBase, DataArk, and MedAssets Claim management and Knowledge source in an effective and proficient manner. Actively participate in service recovery and customer service activities to ensure a superior customer contact. Compliance with established CRH’s confidentiality policy standards or agreements for all information related to patients, family and friends, hospital employees, physicians, and clients.
Maintain effective interdepartmental communication. Maintain professional growth and development through seminars, workshops, outside conferences, additional courses, and professional affiliations. Fiscal responsibility measured on accuracy, quality of work output.
Consistently demonstrate good technique in work performance through quality assurance reviews. Summary of Other Job Duties and Expectations Adhere to the Service Excellence Standards and Expectations at Chesapeake Regional Healthcare. Exhibit excellent customer relations to patients, visitors, physicians, and co-workers.
Exhibit courteous communication skills and an ability to work with others, exercising good judgment in performance of job duties. Demonstrate courtesy, compassion, and respect to others in adherence of the hospital's philosophy and policy for promoting positive work and customer environments. Work as a team to continuously improve work quality.
Demonstrate a commitment to flexible work schedules when it is necessary. Present self in a positive manner as reflected by personal attire and etiquette. Attend required hospital-wide orientations, meetings, and in-services.
Supervisory Responsibilities Reports to: Manager, Patient Accounts Qualifications To perform this job successfully, an individual must have at least three years of experience working directly with Medicare hospital Billing and Follow-up experience with at least a total of 5 years working with Hospital claims with knowledge of all payers with extensive knowledge of Medicare, Medicaid, Commercial and Managed Care Payers.
The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the
. Education and Experience
CRCS Certification and or College degree preferred in health care or business-related field or High school diploma with significant with years of patient revenue cycle/process experience in lieu of college degree. Additional specialized training relevant to job responsibility.
3 plus years in a Hospital setting with extensive background in hospital billing and follow-up functions is preferred. Must exhibit very strong and/or been engaged in analytical and compliance issues. Certificates, Licenses, Registrations Applicants must be a Certified Revenue Cycle Specialist (CRCS) upon hire or within twelve months of the start date.
Education High School (required)