Job Description

Responsibilities

•   Monitors compliance the rules and the contractual terms and agreement with the insurance companies and DOH Guidelines 
•   Ensures compliance by the facility pricing structure and the rules for the different patient categories (including self-payer) with implementation 
•   Prepares submission for all the patient invoice (Claims) through electronically. 
•   Maintains and report incorrect charges and charges not captured to Team Billing Lead or Billing Manager. Bill all secondary claims processed on a daily basis that is produced by billing system 
•   Ensures that DRG revisions are billed on a timely manner according to the billing policy 
•   Maintains a high level of productivity while maintaining accuracy. 
•   Maintains a working knowledge of all universal billing guidelines for all assigned payers 
•   Assists and works on all HCPCS revisions for rebills daily. 
•   Analysis and rebilling of late charges. Rebilling must be done for all late charges according to current policies 
•   Organizes, negotiate, and communicate clinical claim denials with internal clinical staff and the financial services department, as well as external claims representatives of a variety of insurers 
•   Participates in external payer meetings, presenting payer performance related to denials 
•   Serves as the Subject Matter Expert (SME) for clinical denials documentation and payer clinical guideline 
•   Conducts follow-up on claims unpaid, partially paid or denied, including appeals and resubmission to the insurance company 
•   Maintains claims documentation 
•   Assists in the development of reporting mechanisms to identify trends 
•   Delivers solutions to simpler issues facing the employees and presenting complex issues to the Senior Billing and Revenue recoveries 
•   Corresponds with different vendors for the purpose of account verification and details of payment. 
•   Consults with other disciplines and other ancillary departments (i.e. physician, coding, OR, cardiology, pharmacy, purchasing, case management, respiratory therapy, clinical 
documentation specialists, etc.) as needed to obtain necessary documentation to support the clinical appeal and implement prevention 
•   Promotes effective communication strategies within the team and maintains interdepartmental liaison where necessary 
•   Manages to work with all stakeholders when identifying trends that can lead to inappropriate denial 
•   Proactively identifies problems and opportunity for improvements related to system usage, training and end user education, practice and user trends and makes recommendations to the Manager of Revenue Recovery for resolution 
•   Identifies, monitors and presents monthly denial performance accompanied with case studies and recommendations for process improvement 
•   Manages to respond to verbal and written inquiries in a timely manner. 
Accountabilities 
•    Maintains and creates invoices and billing materials to be sent directly to a customer or patient. Ensures payment history, upcoming payment information or other financial data into an individual account. 


 

Qualifications

Experience :-  
Required: 
•   Extensive knowledge of healthcare revenue cycle systems 
•   A minimum of (5) years of healthcare customer service, claims, denials, appeals, compliance or related experience is require 
•   Strong knowledge of third-party payer reimbursement, eligibility verification process and government and payer compliance rules 
•   Knowledge of general medical terminology, CPT, ICD-9 and ICD-10 coding 
•   Strong knowledge of third-party payer reimbursement, eligibility verification process and government and payer compliance rule 

Desired: 
•   Experience in a large healthcare facility 
•   Experience in training and staff development 
 Educational Qualification: Required: 
•   Bachelor in Accounting/Finance/Commerce or relevant field 

Desired: 
•   Clinical Coding Certification, BS in Accounting, Finance, Business Administration or Healthcare. 
•   Master’s in Business Administration or Healthcare preferred 
•   Healthcare Certification (FHFMA and/or FACHE) preferred