PFS Professional Medical Billing Specialist

PURPOSE OF THIS POSITION

This position is responsible for all medical claims including pre-billing and follow up activities for delayed claims by ensuring, through various activities, that claims are clean and should be paid promptly by insurers without requiring further intervention. This staff member performs all pre-claim submission activities, including verifying existing information is accurate, determining when additional data is needed, and collecting necessary details to ensure claims are complete. Additionally, this individual follows departmental productivity and quality control measures that support the organization’s operational goals. This position promotes revenue integrity and accurate reimbursement for the organization by ensuring timely and accurate billing, timely payer follow-up activities and collection of accounts.

JOB DUTIES / RESPONSIBILITIES

• Duty 1 : Maintains a thorough understanding and education of federal and state regulations and payer specific policies and requirements to promote compliant claims submission practices. Adheres to HIPAA related privacy, security and transaction & code set regulations in compliance with the federal guidelines. Accurately documents all account activity.
• Duty 2 : Accurately and efficiently works daily electronic billing file through the organization’s billing system by resolving all necessary corrections with valid resolution to obtain a clean first-time reimbursement.
• Duty 3 : Corrects all claims issues prior to submission which may be, but are not limited to, quality audits of patient demographic information and insurance eligibility, cross referencing with previous services, verifying payer authorizations, identifies and bills missing and late charges and corrects all necessary discrepancies. Submits required clinical documentation for submission with claims and collaborates with additional departments of the hospital to ensure claims are ready for billing and first-time payment.
• Duty 4 : Educates staff in other departments when existing documentation is not sufficient for billing.
• Duty 5 : Prepares and submits manual insurance claims to payers who do not accept electronic claims or who require special handling.
• Duty 6 : Monitors and analyzes error reports to identify significant trends, process improvements or efficiencies and increase accuracy to achieve the overall goals of the department and organization.
• Duty 7 : Monitors outstanding billing holds, escalates accounts as necessary, accurately works delayed claims and reports any trends, issues or findings to supervisor.
• Duty 8 : Observes best practice billing, follow up and customer service activities and reports any suspected compliance issues to supervisor.
• Duty 9 : Identifies high-risk accounts, prioritizes follow up efforts, efficiently contacts various insurance payors to determine reasons for outstanding claims and proactively communicates to facilitate timely payment of submitted claims.
• Duty 10 : Investigates any over / underpayments and communicates with payers when necessary to rectify any pending or delayed claims.
• Duty 11 : Proactively recognizes and rectifies any issues to prevent future insurance payor audits and communicates findings promptly to leadership.
• Duty 12 : Regularly attends and actively participates in staff meetings, training and continuing education that aligns with recognized improvement opportunities, payer policies and procedures and ensures to maintain up to date certifications.
• Duty 13 : The above duties reflect the general duties considered necessary to describe the principal functions of the job as identified and should not be considered a detailed description of all the work requirements that may be inherent to the position.

REQUIRED QUALIFICATIONS

PREFERRED QUALIFICATIONS

PHYSICAL DEMANDS

This position requires a full range of body motion with intermittent activities in walking, lifting, bending, squatting, climbing, kneeling, and twisting. The associate will be required to sit for five hours a day. The individual must be able to lift ten to twenty pounds and reach work above the shoulders. This position requires corrected vision and hearing in the normal range. The individual must have excellent eye-hand coordination and verbal communication skills to perform daily tasks.