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.
Essential Duties 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 b illing edits and/or warnings and billing edits that are identified in the Pat i ent 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 inform ation contained within the Patient Accounting and Billing system to make decisions on how to proceed with the billing of an account.
+ Processes rejections by correcting any billing error and resubmit t ing claims to government and non-government payers .
+ Place unbillable claims on hold and properly communicate to va rious Hospital departments the information needed to accurately bill.
+ 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 c la im 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 rev i ewing 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 leve ls , 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 requiremen ts are met
+ Keep abreast of payer-specific and government requirements and regulations
+ Follow up on unprocessed or unpaid c l aims unti l a c l aims resolution is achieved
+ Generates letters to insurance or patients as needed in order to resolve unpaid claim issues.
+ 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 account.
+ Work independently and has the ability to make decisions relative to i ndividual work activities
+ Identify comments in the billing systems by using in i tials 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 bill i ng 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 .
Education and Experience
Education: CRCS Certification and or College degree preferred in health care or business related field or High school diploma is significant with years of patient revenue cycle/process experience in lieu of college degree. Additional specialized training relevant to job responsibility.
Experience: 5 plus years in a Hospital setting with extensive background in hospital billing and follow-up functions. 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.