Medicare Billing and Follow-up Rep
Chesapeake Regional Healthcare
The Medicare Billing and Follow-up Representative is responsible for the compliant, accurate and timely billing and follow-up of all hospital Medicare and Medicare Advantage Patient Accounts.
Essential Duties and Responsibilities
The duties and responsibilities described below represent the general tasks performed on a daily basis, but are 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.
- Complete special project assignments in a timely fashion
- Follows HIPAA guidelines in order to maintain strict confidentiality of all patient financial and hospital information at all times.
- Perform other duties as assigned
- Analysis, identification of trends, validation, and compliance as related to revenue cycle activities, generating additional revenue to include denials management
- Perform a deep dive quality review of account worked for all billers and follow-up staff.
- Ensure effective and efficient work flow of the department and assist with individual workflow design.
- Troubleshoots; follows through and resolves issues related to the patient revenue cycle, develops and presents recommendations for further consideration by management.
- Keep abreast of updates, rules, requirements and regulations for all government payers
- Demonstrate knowledge of contract terms for multiple insurance carriers
- Assignments defined by management as special projects/analysis to be completed in a timely manner
- Submit electronic and paper claims to appropriate insurance payers as directed
- Follow up in a timely manner on unprocessed, unpaid and/or denied claims until resolution is reached by working work queues
- Make phone calls, use the internet, or send emails per payer specifications to follow up on claims in question
- Enter and analyze information in billing system to record action in clear concise manner
- Ensure that all documentation is clear, concise, and to the point, but contains enough information for understanding of work performed and actions needed
- Ensure that the appropriate documentation, correspondence, emails, etc. are scanned into accounts for accurate documentation of work performed and status of the account
- Research credit balances to resolve accounts when needed
- Understand and use the department computer systems: MPF, Epic HB, OnBase, DataArk, and MedAssets Claim management and Knowledge source in an effective and proficient manner
- Actively participate in service recovery and customer service activities to ensure a superior customer contact
- Compliance with established CRH’s confidentiality policy standards or agreements for all information related to patients, family and friends, hospital employees, physicians, and clients
- Maintain effective interdepartmental communication
- Maintain professional growth and development through seminars, workshops, outside conferences, additional courses, and professional affiliations
- Fiscal responsibility measured on accuracy, quality of work output.
- Consistently demonstrate good technique in work performance through quality assurance reviews
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.
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.