Medicaid/Medicare Billing Specialist

Job Summary:

Responsible for the timely and accurate resolution of insurance claims, primarily for Medicare, Medicaid, and HMO plans. This role involves follow-up on claims from billing through final resolution, identifying and correcting errors, and ensuring prompt payment of outstanding accounts.

Key Responsibilities:

• Claim Follow-up:
  • Monitor the progress of insurance claims from submission to payment 
  • Payers Include Medicare, Medicare HMO's, Medicaid and Medicaid HMO's
  • Identify and resolve claim denials, rejections, and delays.
  • Follow up with insurance carriers to expedite claim payments.
• Error Correction:
  • Review daily electronic billing reports, paper claim submissions, and third-party confirmation reports for errors.
  • Make necessary corrections in the billing system to ensure accurate claims.
• Medicare Claims:
  • Process Medicare RTP claims and denial reports on a daily basis.
  • Ensure timely and accurate submission of Medicare credit balance quarterly reports.
• Account Resolution:
  • Research outstanding accounts and take appropriate action to secure prompt payment.
  • Analyze system-generated reports to identify accounts requiring research.
  • Document all resolution activities in the appropriate system and log.
  • Alert supervisors or managers of non-payment trends.
• Contractual Allowance:
  • Research partial payments to determine if the appropriate contractual allowance was calculated.
  • Initiate corrective action for miscalculated allowances, including collaboration with clinical departments.
  • Document results and alert supervisors or managers of trends.
• Rejected and Denied Services:
  • Research rejected or denied services and determine corrective action.
  • Complete corrective action using departmental procedures and policies.
  • Document results and alert supervisors or managers of non-payment trends.
• Reporting:
  • Complete productivity reports and submit to supervisors within the established timeframe.
• Customer Service and Performance Improvement:
  • Support the department's customer service and performance improvement goals.
  • Collaborate with other staff to enhance patient care and service.
• Compliance:
  • Maintain strict confidentiality of patient information.

Required Qualifications:

• Experience: 1-3 years of experience in healthcare billing or Hospital billing. 
• Technical Skills: Proficiency in using billing systems and software.
• Knowledge: Knowledge of Medicare, Medicaid, and HMO billing regulations.