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Billing Specialist I

4 months ago

Hollywood, United States Memorial Healthcare System Full time

At Memorial, we are dedicated to improving the health, well-being and, most of all, quality of life for the people entrusted to our care. An unwavering commitment to our service vision is what makes the difference. It is the foundation of The Memorial Experience.

Summary:
The Billing Specialist is responsible for resolving claim edits for payors using the knowledge of the appropriate billing form and billing guidelines as well as various insurance contracts and payment methodologies to ensure a compliant claim. Reviews the claims to confirm the correct insurance filling order to ensure the correct payment at the time of initial submission. Ensures compliant billing based on the Office of Inspector General (OIG), CMS, HIPPA and any specific payor regulation. Proactively works accounts to maximize accurate and timely submission of claims utilizing knowledge of all billing guidelines.

**Responsibilities**:
Reviews coding to ensure that the procedures coded are billable according to the regulations set by the different payors. Adds applicable billing modifiers, when needed. Resolves clearinghouse errors and resubmits the claim for processing. Bills secondary or tertiary insurance by interpreting the explanation of benefits (EOB) from the payor. Adjusts or bills late charge/credit replacement claims using insurance payment methodologies.

Resolves payor gateway rejections using payor systems (EDI) information and analysis of the claim issue - for Hospital billing.

Resolves edits in charge review/charge router work queues to ensure complaint billing based on medical documentation - for Physician Billing.

Resolves error in claim edit work queues for accurate and timely submission of paper and/or electronic claims. Uses OIG, CMS and HIPPA guidelines to refer a claim to the appropriate department for review and resolution of the errors, as needed.

Confirms and corrects patient insurance information by calling the guarantor and/or mail inquires for accident insurance, workman's comp, or other needed insurance information. Updates account with any discovered insurance and notates the account with the new insurance information. Applies the unsolicited 271 transaction to add the insurance to the account, when applicable. Applies the unsolicited 271 transaction to add the insurance, when applicable - for Hospital billing.

Creates and submits Part B only claim to Medicare for inpatient services when Medicare Part A benefits are exhausted. If another insurance is also available for billing, reviews and submits a claim for the non-covered Part A services to that payor for payment. for Hospital billing.

Resolves claims edits monthly for skilled nursing/long term care for accurate and timely submission of paper and/or electronic claims. for Hospital billing.

Documents all billing activities in patient account record to accurately reflect what changes have been made to the claim/or insurance information. Identifies billing errors trends and directs these trends to management for review and/or resolution.

Enters all Recovery Audit Contractor (RAC) reviews into the third-party software. Requests medical records and coordinates the response to the RAC request. for Hospital billing

Requests and submits appropriate medical records to selected insurance companies or Medicare either for initial billing requirements or to respond to Additional Documentation. Requests (ADR) for oncology services. Works with audit nurses on coordination of medical records and letter of medical necessity for a formal appeal. for Hospital billing.

Works in appropriate claim system for Medicare and Medicaid to resolve overpayments by the payor by updating claim information in their system. - for Hospital billing.

Competencies:
ACCOUNTABILITY, ACCURACY, ANALYSIS AND DECISION MAKING, BILLING, CUSTOMER SERVICE, PROBLEM SOLVING, RESPONDING TO CHANGE, STANDARDS OF BEHAVIOR

Education and Certification Requirements:
High School Diploma or Equivalent (required)

Additional Job Information:
Complexity of Work: Requires excellent communication skills, critical thinking skills, decisive judgment and the ability to work with mínimal supervision. Knowledge of UB-04 and/or CMS 1500 form, billing guidelines, insurance contract and payment methodologies. Must be able to work in a stressful environment and take appropriate action. Required Work Experience: No prior experience required. For Hospital Billing, the knowledge of UB-04 and EPIC hospital billing experience preferred. For Physician Billing, the knowledge of CMS 1500 and EPIC professional billing experience preferred.

Working Conditions and Physical Requirements:

- Bending and Stooping = 0%
- Climbing = 0%
- Keyboard Entry = 80%
- Kneeling = 0%
- Lifting/Carrying Patients 35 Pounds or Greater = 0%
- Lifting or Carrying 0 - 25 lbs Non-Patient = 60%
- Lifting or Carrying 2501 lbs - 75 lbs Non-Patient = 0%
- Lifting or Carrying > 75 lbs Non-Patient = 0%
- Pushing or Pulling 0 - 25 lbs Non-Patient = 60%