Billing Specialist I - FT - Days - MSS

Memorial Healthcare

About The Position

The Billing Specialist resolves claim edits for payors using knowledge of billing forms and guidelines, insurance contracts, and payment methodologies to ensure compliant billing. The role reviews claims to confirm the correct insurance filing order and support accurate payment at initial submission. It ensures billing complies with Office of Inspector General (OIG), CMS, HIPAA, and payor-specific regulations, and proactively works accounts to maximize accurate and timely claim submission. The position requires excellent communication and critical-thinking skills, decisive judgment, and the ability to work with minimal supervision. The specialist must know UB-04 and/or CMS 1500 forms, billing guidelines, insurance contracts, and payment methodologies, and be able to work in a stressful environment and take appropriate action. No prior experience is required. Hospital billing experience with UB-04 and EPIC is preferred; physician billing experience with CMS 1500 and EPIC is also preferred.

Requirements

High school diploma or equivalent.
Knowledge of UB-04 and/or CMS 1500 forms, billing guidelines, insurance contracts, and payment methodologies.
Excellent communication and critical-thinking skills.
Decisive judgment and ability to work with minimal supervision.
Ability to work in a stressful environment and take appropriate action.

Nice To Haves

For hospital billing, knowledge of UB-04 and EPIC hospital billing experience.
For physician billing, knowledge of CMS 1500 and EPIC professional billing experience.

Responsibilities

Document billing activities in patient account records, including changes made to claims or insurance information.
Identify billing error trends and direct them to management for review or resolution.
For hospital billing, enter Recovery Audit Contractor (RAC) reviews into third-party software, request medical records, and coordinate responses to RAC requests.
For hospital billing, request and submit medical records to insurers or Medicare for initial billing requirements or Additional Documentation Requests for oncology services; coordinate records and letters of medical necessity with audit nurses for formal appeals.
For physician billing, resolve charge review and charge router work-queue edits to ensure billing complies with medical documentation.
Resolve claim-edit work-queue errors to support accurate and timely submission of paper and electronic claims; use OIG, CMS, and HIPAA guidelines to refer claims to the appropriate department when needed.
For hospital billing, resolve payor gateway rejections using payor EDI systems and claim analysis.
Review coding to ensure procedures are billable under payor regulations and add applicable billing modifiers when needed.
Resolve clearinghouse errors and resubmit claims for processing.
Bill secondary or tertiary insurance by interpreting payor explanations of benefits.
Adjust or bill late-charge and credit-replacement claims using insurance payment methodologies.
For hospital billing, use appropriate Medicare and Medicaid claim systems to resolve payor overpayments by updating claim information.
For hospital billing, resolve monthly skilled-nursing and long-term-care claim edits for timely and accurate paper or electronic submission.
Confirm and correct patient insurance information by contacting guarantors or sending inquiries regarding accident insurance, workers’ compensation, or other needed insurance; update and annotate accounts with discovered insurance information and apply unsolicited 271 transactions when applicable.
For hospital billing, create and submit Part B-only Medicare claims for inpatient services when Part A benefits are exhausted, and submit claims to other available insurers for non-covered Part A services.