Billing & Claims Spec 1 MGBO

Wellstar Health System • VIRTUAL-GA, GA

8d

About The Position

The Billing and Claims Specialist I manages claim processes, including accurate and timely claim creation, follow-up, and correspondence with providers and insurers. The specialist processes paper and electronic claims with complete information, works claim edits in Epic EMR and an external claim scrubber before submission, and handles payer rejections, retro-adjudicated claims, and claims requiring an internal claim number. The role also helps clarify and develop process improvements, ensures payments from all sources are recorded and reconciled promptly, and supports revenue maximization and denial reduction.

The position prepares, submits, researches, and corrects claims; coordinates patient eligibility checks; documents account billing activity; attaches payer-required documentation; and follows up on denials and insurance issues. It also includes professional communication with patients, families, healthcare teams, and internal departments, as well as teamwork, continuing education, and participation in performance-improvement activities. The specialist follows applicable Wellstar policies, regulatory requirements, confidentiality rules, and HIPAA guidelines.

Requirements

• High school diploma or GED.
• At least 1 year of medical billing experience, including knowledge of billing-related reporting; alternatively, experience working with medical payers including Medicare, Medicaid, and commercial insurance is required.
• Working knowledge of CPT and ICD-10 coding systems.
• Knowledge of medical billing and collection practices.
• Ability to work well with deadlines and be results oriented.
• Good communication and customer-service skills when interacting with patients, coworkers, and physician practices.
• Strong problem-solving and analytical aptitude.
• Excellent time-management skills and ability to work independently.
• Ability and willingness to demonstrate behaviors consistent with performance-improvement standards and organizational values, including financial responsibility, safety, partnership and service, teamwork, compassion, integrity, trust, and respect.

Responsibilities

• Prepare and submit clean electronic or paper claims to third-party payers.
• Analyze and research claim submission edits and payer rejections, resolving them using medical-record information, CMS rules and regulations, CPT coding guidelines, and departmental policies.
• Work with the Change Healthcare clearinghouse, including follow-up and support issues.
• Coordinate patient eligibility processes through third-party sources.
• Document and explain billing activity in the appropriate patient-accounting fields.
• Identify and resolve patient billing issues and manage denial and insurance follow-up.
• Attach payer-required documentation and mail paper claims when needed.
• Meet current productivity and quality standards for processing electronic and paper claims.
• Issue adjusted, corrected, and rebilled claims to third-party payers.
• Identify opportunities for system and process improvement.
• Follow Joint Commission and other regulatory requirements, HIPAA guidelines, and Wellstar and departmental policies and procedures.
• Resolve payer rejections, ICN claim errors, Master File errors, retro-review visit-filing-order updates, and assigned transfer work queues.
• Resolve miscellaneous work-queue errors and review or override external clearinghouse edits.
• Complete Railroad Medicare claim submissions.
• Maintain patient and family confidentiality and privacy, and ensure minors have a parent or guardian listed as guarantor when appropriate.
• Communicate professionally with patients, families, peers, healthcare-team members, referral agencies, and internal customers, including HIM, Revenue Integrity, Patient Access, and Patient Financial Services.
• Assist with special projects and collaborate with staff and healthcare-team members to support an effective work environment.
• Report on assignments and projects, initiate problem solving and conflict resolution, and report to work on time as scheduled.
• Attend staff meetings, in-services, and continuing education; assist with assigned indicator, threshold, study-method, and data-collection development.
• Respond to opportunities to improve care and customer service, support system performance-improvement initiatives, and maintain required competencies.
• Perform other duties and responsibilities as assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED