Billing and Utilization Management Specialist (77731)
About The Position
This role is responsible for ensuring accurate claims processing and follow-up, researching and resolving billing issues, and managing electronic and manual posting of payments and adjustments. The specialist will track outstanding claims, prepare and submit claims accurately, and utilize the EHR system to audit claim status. They will also communicate effectively with internal and external customers regarding individual accounts, create invoices, process credit memos, and monitor account details for non-payments. A key part of the role involves verifying medical necessity, service authorization, and payer requirements, submitting MNS data for authorizations, and ensuring accurate processing of authorization data within consumer payer records. The specialist will also identify and resolve MNS data discrepancies and obtain approvals for services.
Requirements
- Possesses a high school diploma or General Educational Development (GED) certificate.
- Specific knowledge of billing processes and practices.
- Experience in medical billing or revenue cycle operations preferred.
- Maintains current knowledge of billing and utilization management practices as typically acquired through continuing education.
- A valid state-issued driver’s license is required.
- Prepares basic correspondence and simple reports in Microsoft Word.
- Uses Microsoft Excel to create tables and simple displays of information.
- Creates basic presentations in Microsoft PowerPoint.
- Demonstrates necessary proficiency with all electronic clinical systems, including EHR and scheduling systems, in use at the Company.
- Functions effectively in response to workflow or ongoing direction by supervisors.
- Effectively selects from pre-established alternatives to resolve situations encountered on the job.
- Provides or exchanges routine information.
- Exercises tact and diplomacy in the resolution of mild conflicts or disagreements.
Nice To Haves
- Experience in medical billing or revenue cycle operations preferred.
Responsibilities
- Ensures accurate claims processing and follow up.
- Researches and resolves issues with claim rejections or other billing issues.
- Performs electronic and manual posting of both insurance and persons served payments/adjustments to individual’s accounts.
- Tracks outstanding claims, investigates issues, and coordinates corrections or appeals.
- Prepares, reviews, and submits claims with accuracy and adherence to payer requirements.
- Utilizes EHR optimally to audit claim status and troubleshoot issues.
- Provides professional and effective communication with internal and external customers as related to individual accounts.
- Creates and issues invoices and payment reminders to persons served.
- Processes credit memos and prepares account statements.
- Monitors account details for non-payments and irregularities.
- Communicates with payers, staff, and persons served to clarify documentation, eligibility, service, or claim needs.
- Verifies medical necessity, service authorization, and payer requirements for ongoing or planned services.
- Submits medically necessary services (MNS) data electronically or manually to state-assigned contractors to secure service authorizations.
- Imports authorization data efficiently, ensuring accurate processing within consumer payer records.
- Identifies and resolves MNS data discrepancies in collaboration with clinical staff to facilitate timely authorization requests.
- Obtains and documents approvals for services, ensuring timely submission of required clinical information.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
