Business Office Specialist

SECTION 1: Job Summary (Summary of the basic functions of the position)

Responsible for medical billing from insurance companies (payors) and patients. Serves as a liaison
between practices, clinics, the business office, payors, and patients. Establishes and maintains contacts
with payor accounts’ representatives. Initiates telephone contact and answer all calls pertaining to
accounts. Maintains accurate information regarding patient accounts receivable. Maintains strict
confidentiality for all patient accounts. Follows approved processes, policies and procedures in executing
job duties.

SECTION 2: Duties and Responsibilities (Responsibilities necessary to accomplish job functions)

• Reviews claims and claim edits in Availity and other payer portals to identify and resolve billing errors or rejected claims prior to or following submission.

• Researches and resolves claim edits related to missing, invalid, or incorrect NPI information, including determining the appropriate billing, rendering, or referring provider information required by the payer.

• Uses Availity to review payer claim edits, rejection messages, claim status, payer requirements, and other information necessary to resolve billing issues.

• Researches payer-specific requirements through Availity and payer resources to determine the appropriate corrections needed for successful claim submission.

• Corrects applicable claim information in NextGen and resubmits or routes claims for correction in accordance with established billing procedures.

• Documents claim edit resolution and communicates recurring issues to appropriate billing, coding, credentialing, or management staff.

• Performs payer profile/file maintenance in NextGen to maintain accurate payer and insurance information.

• Creates, updates, and maintains payer profiles, including payer names, payer identification numbers, payer addresses, electronic payer information, claim submission information, and other payer-specific billing requirements.

• Ensures all claims are properly bill and clean claim submission through NextGen

  • Tertiary paper claim printing
  • Ensuring proper provider/location profile setup prior to start date.
• Keys data into computer to maintain billing records and prepare insurance form with data such as names of insurance company and policy holder, policy number, and physician diagnosis.
• Contacts insurance company to verify patient coverage and obtain information concerning extent of benefits.
• Reviews all insurance claim forms for accuracy and correct coding, retrieving and attaching appropriate dictation for claim, as needed.
• Reviews all insurance payments (Explanation of Benefits – EOB’s), including Medicare and Medicaid payments for accuracy in account information and demographics.
• Determines adjustments of claims paid at the out-of-network rate to in-network rates, and processes write-offs on these adjustments.
• Posts all payments, including insurance and patient payments, to appropriate accounts.
• Computes total surgery bill showing amounts to be paid by insurance company and by patient.
• Answers patients' questions regarding statements and insurance coverage, answers telephone in a prompt, courteous, and helpful manner, screening calls, directing calls, providing information, answering questions, and taking accurate messages.
• Responds to all inquiries received from patients and payors either by telephone or written request
• Follows-up on unpaid insurance claims after denial, to obtain settlement of claim.
• Establishes and maintains contacts with payor accounts’ representatives.
• Reviews accounts receivable activities and calls on outstanding balances or claims.
• Processes patient refunds as needed.
• Handles transactions necessary on discharged patients.
• Completes and files all necessary paperwork for services rendered, i.e., charge tickets, patient forms, medical records, etc.
• Adheres to all safety policies and procedures in performing job duties and responsibilities while supporting a culture of high quality and great customer service.
• Performs other duties that may be necessary or in the best interest of the organization

SECTION 3: Experience Requirements

• Three (3) years of work experience in medical billing and accounting experience.

SECTION 4: Knowledge, Skills and Abilities Requirements

• Thorough knowledge of medical billing coding, including CPT and ICD-10 coding required
• Thorough knowledge of Medicare rules and regulations.
• Thorough knowledge of medical billing procedures and medical insurance, including credit and collection procedures required.
• Thorough knowledge of medical accounts receivable collection procedures, including knowledge of insurance correspondence required.
• Detail oriented, professional attitude, reliable
• Management and organizational skills to support the leadership of this function
• Ability to follow or provide verbal & written instructions with sufficient grammar and spelling skills to avoid mistakes or misinterpretations
• Interpersonal skills to support customer service, functional, and team mate support needs
  • Able to communicate effectively in English, both verbally and in writing
• Mathematical and/or analytical ability for basic to intermediate problem solving
• Basic to intermediate computer operation
  • Proficiency with Microsoft Excel, Word, and Outlook
• Specialty knowledge of systems relating to job function
• Knowledge of state and federal regulations for this position; general understanding of HIPAA guidelines

SECTION 5: Supervisory Responsibilities:

• This position has no supervisory responsibilities.