Billing and Utilization Management Specialist

Primary Responsibilities and Duties

• Ensures accurate claims processing and follow up.
  • Researches and resolves issues with claim rejections or other billing issues.
  • Performs electronic and manual posting of both insurance and persons served payments/adjustments to individual’s accounts.
  • Tracks outstanding claims, investigates issues, and coordinates corrections or appeals.
  • Prepares, reviews, and submits claims with accuracy and adherence to payer requirements.
  • Utilizes EHR optimally to audit claim status and troubleshoot issues.

• Provides professional and effective communication with internal and external customers as related to individual accounts.
  • Creates and issues invoices and payment reminders to persons served.
  • Processes credit memos and prepares account statements.
  • Monitors account details for non-payments and irregularities.
  • Communicates with payers, staff, and persons served to clarify documentation, eligibility, service, or claim needs.
• Authorization Management, Compliance, & Data Integrity.
  • Verifies medical necessity, service authorization, and payer requirements for ongoing or planned services. Submits medically necessary services (MNS) data electronically or manually to state-assigned contractors to secure service authorizations.
  • Imports authorization data efficiently, ensuring accurate processing within consumer payer records
  • Identifies and resolves MNS data discrepancies in collaboration with clinical staff to facilitate timely authorization requests.
• Obtains and documents approvals for services, ensuring timely submission of required clinical information.

Primary Attributes

Professional & Technical Knowledge:

• Possesses a high school diploma or General Educational Development (GED) certificate as well as specific knowledge of billing processes and practices, typically learned “on the job,” or which may include a series of training sessions that would comprise a few weeks if done consecutively. Experience in medical billing or revenue cycle operations preferred.

Continuing Education:

• Maintains current knowledge of billing and utilization management practices as typically acquired through continuing education.

Licenses & Certifications:

• A valid state-issued driver’s license is required.

Technical Skills:

• Prepares basic correspondence and simple reports in Microsoft Word. Uses Microsoft Excel to create tables and simple displays of information. Creates basic presentations in Microsoft PowerPoint. Demonstrates necessary proficiency with all electronic clinical systems, including EHR and scheduling systems, in use at the Company.

General Development:

• Functions effectively in response to workflow or ongoing direction by supervisors. Effectively selects from pre-established alternatives to resolve situations encountered on the job. Provides or exchanges routine information. Exercises tact and diplomacy in the resolution of mild conflicts or disagreements.

Work Environment:

• Work is performed in a typical office environment.