Claims/Billing Specialist

Objective: Clean claim billing and timely follow up for emergency and non emergency transports.

Essential Duties:
 Know and support the Mission Statement, Policy/Procedures and standards of MMR.
 Proficient with billing and prebilling the following insurances: Medicare, Medicaid, BCBS, and Commercial including
auto hospice etc.
 Verify coverage through C-Snap, Web Denis, and Trizetto.
 Utilize hospital websites to obtain insurance information.
 Verify coverage and auto insurance for claim/billing information over the phone, as necessary.
 Obtain authorization number and record the authorization number in the required field, prior to prebilling the claim.
 Contact patient for insurance information when correct information is not initially provided.
 Review Physician’s Certification Statement (PCS) for proper signature, medical necessity, and completeness.
 Obtains repetitive Physician Certification Statement (PCS) when needed 14 days prior to the expiration of a current
PCS.
 Proficiently verify all insurances that relate to the claim.
 Verify and correct patient demographic information.
 Add CMS signature when obtained.
 Maintains HIPAA compliance.
 Pre-bill all emergency and non-emergency claims.
 Understand proficiently Tier 1/Tier 2, ALS 1 with and w/o ProQA/EMD) ALS 2, SCT/Neonate/Emergency and nonemergency
transports and how these assist in determining the charges.
 Understand proficiently EMT-Basic, EMT-Paramedic, Specialty Care Transport (SCT) trained staff.
 Places claim in appropriate schedule i.e., Auto 1/Neonate 1/Care/Caid, etc.
 Maintain HIPAA compliance.
 Follows up on claims within 30 days after being sent to the payer.

Medicare/Medicaid follow-up:
 Complete Medicare requests, process follow up rejections/denials and appeals for Medicare and Medicaid claims.
 Process Medicare and Medicaid refunds.
 Follow-up on lacking Medicare Signatures via mail/phone calls.
 Resubmit accounts when new or corrected information is obtained from the caller or payer.

Blue Cross Blue Shield (BCBS) follow-up:
 Complete BCBS/Patient Care Report (PCR) information requests.
 Process BCBS rejections/denials.
 Process BCBS refunds.

Commercial follow-up/Patient Pay
 Follow-up with commercial payers including auto.
 Assists Patient Pay follow up as necessary.
 Process commercial insurance and patient payment refunds.

 Perform other duties as assigned.

Knowledge, Skill and Competency Requirements:
 Medical office experience and familiarity with insurance billing practices preferred
 Must proficiently use insurance websites i.e., C-Snap, Champs, Web Denis, etc., 2 months after date of hire
 Reading skills to comprehend correspondence and materials specific to the healthcare industry
 Must demonstrate ability to maintain security and confidentiality with utmost discretion
 Ability to communicate effectively both verbally and in writing, in the English language
 Ability to organize tasks and insure timely completion of all projects
 Advanced computer skills including the ability to utilize a computer PC with Windows operating system
 Ability to operate office equipment, including but not limited to, copier, fax machine, scanner, monitor, multi-line telephone, printer, typewriter and calculator
 Proficiency with Microsoft Word and Excel
 Regular attendance and timeliness
 Skilled in typing, data entry, scanning, electronic filing and document retrieval
 Proficiency with billing the following insurances, Medicare, Medicaid, BCBS, Commercial
 Ability to communicate professionally, effectively both verbally and in writing, in a professional manner with customers and patients
 High School Diploma
 Must be at least 18 years old

Physical Factors: Suitable dexterity to operate standard office equipment. Capability to stand or sit for extended periods of time.

Working Conditions: Most work is done in a typical office setting with daily exposure in all other department areas. Regular, in-person attendance is an essential function of the job. Materials and equipment used include desktop computer, telephone, fax, copier, printer and other standard office equipment. Hours must be flexible to meet the demands of the office.