Summary: Submits medical insurance claims with commercial insurance carriers, Medicare and Medicaid, electronically, when possible, and by paper; posts insurance and patient payments to patients’ accounts. Verifies submitted charges with providers, if necessary, and assists patients in understanding charges and payments to their accounts. Performs denial management and follow-up on unpaid claims for resolution, in a timely manner.
Essential Duties and Responsibilities:
Reviews daily charges/previous days’ appointments and creates/submits all claims. Verifies diagnosis, provider number, patient ID number, verifying the correct charges where processed, based on the encounter types. Submits primary and secondary insurance claims within 48 hours of rendering service or posting of primary remit.
Reviews code assignments and assigns modifiers when appropriate for clean claim filing. Queries providers as needed to ensure accuracy.
Reconciles daily claim submission though clearinghouse to ensure all claims and claim edits are correct and transmitted on to payers. Any discrepancies in claims submitted totals and claims acknowledged are noted and resolved within 48 hours of initial submission.
Accurately posts payments from all payers; proof, balance, close payment entry and file with the day’s transaction reports. Reconciles all deposits and EFTs with EOB remit files, both electronically and on paper.
Researches all claims paid in error or denied, defines denial and codes appropriately based on standard HIPAA reason and remark codes, and reports trends or unusual denials to the Director. Demonstrates an understanding of payer fee schedules and encounter rates to monitor payment rate accuracy.
Files appeals timely and/or manages denials online with payers to ensure accurate payments are received. Corrects and re-submits claims only when needed; conducts follow up in a timely manner with insurance carriers on denied claims and when necessary to understand denial reason(s) and/or to determine corrective action needed.
Performs accounts receivable (A/R) follow-up on all unpaid claims at intervals set forth in performance standards to ensure timely resolution. Utilizes payer websites, when available, to check claim status and/or to request reprocessing of claims. Demonstrates a clear understanding of all MLMC payers' timely filing limits and appeal time limitations.
Assists patients in understanding charges and payments to their accounts, by phone or in person.
Assists with eligibility verification electronically or by phone with fiscal agencies to assure claim payments.
Maintain strictest confidentiality and assures HIPAA guidelines are adhered to.
Assures compliance with applicable laws and regulations related to billing through demonstrated understanding of CPT, HCPCS and ICD-10-CM coding guidelines. Identifies any aberrant coding practices and notifies management.
Refers patients that may need insurance enrollment to MLMC Insurance Navigators. Ensures appropriate documentation of income verification is on file and current for all Sliding Fee recipients.
Identifies any system-related issues and notifies IT Specialist &/or Director in a timely manner. Participates in support-related calls to resolve system issues when necessary.
Provides excellent patient-centered customer service while being friendly and courteous to all employees and patients; can handle multiple tasks at once and has the ability to compassionately and empathetically care for patients.
Other duties as assigned.
Upholds the Code of Ethics and mission of Mountain Laurel Medical Center in a manner consistent with the core values of patient focused, respect, accountability, teamwork, continuous improvement, and integrity.
Core Values Statement
The patient comes first and is central to all decision making.
Treat all patients and staff the way you expect to be treated.
Each employee owns their actions, and expects the same from all others
It is necessary to work together in a supportive manner to achieve common goals.
Stay committed to the pursuit of excellence, always finding ways to adapt and improve.
Always do the right thing.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skills and ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This position routinely deals with sensitive and confidential information requiring the utmost privacy and confidentiality.
Education and Experience:
A high school diploma is required, additional education/training desirable, and at least three years related experience and training in medical insurance claims filing, or equivalent, preferably in a financial-medical setting, or a combination of education and experience in financial-medical setting. Because insurance regulations and billing guidelines are ever-changing, continued education in CPT, HCPCS and ICD-10 coding, as well as payer updates is necessary. Position requires a minimum of 8 hours continued education either through payer website training, webinars, seminars or other form approved by MLMC management.
Knowledge of practice management and electronic health record is essential. Ability to utilize online resource materials and payer websites for claim management also preferred.
Vast understanding of the different types of insurances and the knowledge and ability to distinguish the differences in coverage, charges, co-pays, denial codes, and denials reasons. Understanding Federally Qualified Health Center or Rural Health Clinic reimbursement and billing preferred.
A demonstrated work record showing good attendance, punctuality, dependability and the ability to work well with supervisors and coworkers as part of a team effort is essential. A medical office setting is an environment that requires the ability to relate to all types of people while always maintaining a professional demeanor.
Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals is essential. Ability to write routine reports and correspondence, and the ability to speak effectively to patients, co-workers and the public at large is paramount.
Must have the ability to calculate figures and amounts such as sliding fees, discounts, interest, proportions and percentages along with mathematical accuracy and attention to detail are essential skills for this position
Must be able to demonstrate the ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
An essential element is the ability to work and interact effectively and positively with other staff members to build and enhance teamwork in the center and in the overall MLMC organization; team engagement is a must to be successful in this position.
Sensitivity to the Needs of Special Populations:
Must be able to demonstrate the ability to understand and respond appropriately, effectively and sensitively to special population groups served by MLMC. Special population groups include those defined by race, ethnicity, language, age, sex, sexual orientation, economic standing, disability, religion, etc.
Understanding of HealthCare laws and Regulations:
Must have the ability to follow HIPAA guidelines as well as an understanding of policies and procedures regarding medical records put in place by the Federal Government.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is frequently required to drive, sit, handle papers, type and operate computer equipment; reach with hands and arms; talk, see and hear. Some local travel may be required.
Work is performed in a typical business office environment and periodically at locations outside the office. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job.
Job Description: Billing Specialist
I have read and understand this position description. I understand that while every effort has been made to describe the nature of the work entailed, this description cannot be construed as an exhaustive list of all responsibilities, duties and skills required for this position. I also understand this position description may be changed in the interest of better patient care or more efficient operation of the health center, and that notification of any change in this position description will be made in writing. I also acknowledge that nothing explicitly stated or implied in this position description alters the “at will” status of my employment relationship with Western Maryland Health Care Corp, doing business as Mountain Laurel Medical Center.