Billing & Electronic Claims Specialist

The Billing/Electronic Claims Specialist performs daily activities associated with the timely submission of medical electronic and paper claims. They will prepare, verify, correct and submit claims to expedite payment from third party carriers.

 Essential Functions:

• Must possess effective and efficient communication, computer to include Microsoft Office Products and phone skills.
• Responsible for monitoring outstanding claims in order to correct claim barriers and secure accurate and timely payments for claims submitted to insurance carriers.
• Responsible for running all assigned reports daily and verifying the report information to ensure claims are being handled properly.
• Must have a detailed understanding of billing rules and regulations to include, but not limited to, edits, LCDs, payor requirements, code denials, procedure codes, diagnosis codes, timely filing and other issues that could result in delayed or denied reimbursement.
• Responsible for completing any and all required actions for all medical claims to be filed either electronically or by paper.
• Responsible for obtaining information from outside resources such as our facilities, HIM, physicians, insurance companies, patients, etc, as needed for claim completion. Information is to be requested from other parties following the CBO policy guidelines.
• Responsible for the importing of claims from billing AR systems to the billing claims scrubber/filing systems.
• Responsible for making sure the claims are sent from the claims scrubber/filing system to the clearinghouses for distribution to the appropriate insurance carriers.  
• Expected to maintain knowledge of and adhere to applicable rules, regulations, policies, laws, contracts and guidelines that impact reimbursement and CBO operations.  Seeks advice and guidance as necessary to ensure proper understanding.
• Effectively working and cooperating with supervisors, co-workers and clients.
• Following the directions of supervisors.
• Refraining from causing or contributing to disruption in the workplace.
• Regular and reliable attendance.
• Performs other duties as assigned.

Functional Accountabilities:

• Print out all assigned daily billing reports and distribute as instructed.
•  Work their assigned reports to completion each day. Reports to be worked daily are listed in the CBO policy.
• Print out applicable error and/or rejection reports from billing AR systems daily.
• Research accounts that show as failed on error and/or reject reports and make necessary corrections for the claim to file to insurance.
• Create and complete processing of billing file from the billing AR system.
• Upload created billing files to the claims scrubber system. At this time we utilize Payorpath and Emdeon.
• Verify that all claims listed in the created file by the host system are accounted for in the claims scrubber system when the upload is completed.
• If claim count or dollar amount does not match between the two systems investigate which claims are missing and make necessary corrections for the claims to file.
• Completes correction of claims that are flagged as containing errors by the scrubbing system.
• If assistance is needed from another resource they request the information and put the claim on hold until it can be resolved and filed.
• After necessary corrections are made to rejected claims will perform system function to refile the claim.
• Review of Accepted/Rejected Reports from carriers.
• For carrier rejected claims correct listed errors and resubmit the claim.
• If error was generated based on information from the host system and information can be updated we will make the update. This will keep the error from repeating in the future.
• Prints claims to paper that will not file electronically to the insurance carrier. Claims are to be mailed same day as printed unless on hold for op notes.
• Distribute to appropriate staff any claims that are rejected that they cannot facilitate.
• Monitors billing system notifications to ensure that claims are accepted by the payor or clearinghouse daily.
• Verifies daily that all claims that could be filed were filed and they are aware of the reasons for any claims left in the scrubber and not filed.
• Responsible for making sure requested information is received from other resources in a timely manner and that the pending claim gets resolved.
• Responsible for making sure return mail and address changes that pertain to insurance companies are handled and system updated with new information as warranted.

Accountability:     

• Reports to: AR Collections Manager - Facilities/ For physician side reports to Coding & Claim Management Manager.
• Supervises: None

Qualifications:  (Minimum education, training and experience, licensure, certification)

• High School Diploma or equivalent required
• Minimum 1 year experience in medical billing required
• Current billing system experience preferred
• Expected to maintain knowledge of and adhere to applicable rules, regulations, policies, laws, contracts and guidelines that impact reimbursement
• Must be able to work independently as well as a team environment

Required Physical Demands:    

• Strength (Lift, Carry, Push, Pull):  Sedentary (exerting up to 10 pounds of force occasionally)
• Standing/Walking: Occasionally; activity exists up to 1/3 of the time
• Keyboard/Dexterity: Constantly; activity exists 2/3 or more of the time.
• Talking (Must be able to effectively communicate verbally): Yes
• Seeing: Yes
• Hearing: Yes
• Color Acuity: No

What We Offer

As an organization, one way we care for our communities and each other is by providing a comprehensive benefits package that includes:

• Medical, dental, vision, and prescription coverage
• Life and AD&D coverage
• Availability of short- and long-term disability
• Flexible financial benefits including FSAs, HSAs, and Daycare FSA.
• 401(k) and access to retirement planning
• Employee Assistance Program (EAP)
• Paid holidays and vacation