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 ABNs 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 websites
• 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
• 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.

Last updated : 2024-03-23