Job Details

Billing Follow Up Medicare

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 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 account.
• 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 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 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 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 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.

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.

Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.