PFS Professional Medical Billing Specialist

PURPOSE OF THIS POSITION

This position is responsible for all medical claims including pre-billing and follow up activities for delayed claims by ensuring, through various activities, that claims are clean and should be paid promptly by insurers without requiring further intervention. This staff member performs all pre-claim submission activities, including verifying existing information is accurate, determining when additional data is needed, and collecting necessary details to ensure claims are complete. Additionally, this individual follows departmental productivity and quality control measures that support the organization’s operational goals. This position promotes revenue integrity and accurate reimbursement for the organization by ensuring timely and accurate billing, timely payer follow-up activities and collection of accounts.

JOB DUTIES / RESPONSIBILITIES

Duty 1 :

Maintains a thorough understanding and education of federal and state regulations and payer specific policies and requirements to promote compliant claims submission practices. Adheres to HIPAA related privacy, security and transaction & code set regulations in compliance with the federal guidelines. Accurately documents all account activity.

Duty 2 :

Accurately and efficiently works daily electronic billing file through the organization’s billing system by resolving all necessary corrections with valid resolution to obtain a clean first-time reimbursement.

Duty 3 :

Corrects all claims issues prior to submission which may be, but are not limited to, quality audits of patient demographic information and insurance eligibility, cross referencing with previous services, verifying payer authorizations, identifies and bills missing and late charges and corrects all necessary discrepancies. Submits required clinical documentation for submission with claims and collaborates with additional departments of the hospital to ensure claims are ready for billing and first-time payment.

Duty 4 :

Educates staff in other departments when existing documentation is not sufficient for billing.

Duty 5 :

Prepares and submits manual insurance claims to payers who do not accept electronic claims or who require special handling.

Duty 6 :

Monitors and analyzes error reports to identify significant trends, process improvements or efficiencies and increase accuracy to achieve the overall goals of the department and organization.

Duty 7 :

Monitors outstanding billing holds, escalates accounts as necessary, accurately works delayed claims and reports any trends, issues or findings to supervisor.

Duty 8 :

Observes best practice billing, follow up and customer service activities and reports any suspected compliance issues to supervisor.

Duty 9 :

Identifies high-risk accounts, prioritizes follow up efforts, efficiently contacts various insurance payors to determine reasons for outstanding claims and proactively communicates to facilitate timely payment of submitted claims.

Duty 10 :

Investigates any over / underpayments and communicates with payers when necessary to rectify any pending or delayed claims.

Duty 11 :

Proactively recognizes and rectifies any issues to prevent future insurance payor audits and communicates findings promptly to leadership.

Duty 12 :

Regularly attends and actively participates in staff meetings, training and continuing education that aligns with recognized improvement opportunities, payer policies and procedures and ensures to maintain up to date certifications.

Duty 13 :

The above duties reflect the general duties considered necessary to describe the principal functions of the job as identified and should not be considered a detailed description of all the work requirements that may be inherent to the position.

REQUIRED QUALIFICATIONS

High school graduate or GED equivalent

CPFSS certifications required within 12 months of hire (PRN status does not require certification)

Familiarity with medical terminology and an understanding of HIPAA requirements

Ability to perform project work which may require independent work or collaboration with others

Proficient in Microsoft Office Programs, especially Excel

Ability to manage multiple tasks and complex issues with excellent time management & organizational skills

Demonstrated problem solving skills with excellent self-direction and creative solutions for operational efficiencies

Adapts positively to changes in the working setting with ease

A valid driver's license is required (if you do not have a valid Ohio driver’s license you must obtain one within 30 days of your residency in the state).

You must also meet BVHS's company fleet policy and insurance company requirements, and any other requirements that may be required to operate a vehicle.

Individual must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patient served on his / her assigned unit / department. The individual must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient status.

Must be able to interpret the appropriate information needed to identify each patient’s requirements relative to their age-specific needs and to provide the care needed as described in the area’s policies and procedures

PREFERRED QUALIFICATIONS

Associate’s degree, CPC certification or 2-3 years of experience in medical billing, coding or other revenue cycle functions preferred

Conversant with various code sets (e.g., ICD-10, CPT, HCPCS, Modifiers, etc.)

Familiarity with data elements on standard billing forms (e.g., CMS-1500)

PHYSICAL DEMANDS

This position requires a full range of body motion with intermittent activities in walking, lifting, bending, squatting, climbing, kneeling, and twisting. The associate will be required to sit for five hours a day. The individual must be able to lift ten to twenty pounds and reach work above the shoulders. This position requires corrected vision and hearing in the normal range. The individual must have excellent eye-hand coordination and verbal communication skills to perform daily tasks.