Skilled Nursing Facility (SNF) HMO Biller-S

PACS

About The Position

The HMO Billing and Collections Specialist records revenue, submits electronic claims, and pursues timely collection from HMO payer sources. The role monitors HMO admissions and claims, verifies eligibility and authorizations, ensures patient records have the correct payer and claim form, and coordinates with assigned centers to resolve billing and collection issues. The specialist ensures claims are accurate, submitted on schedule, and properly recorded, and works with internal teams and payer representatives to maximize revenue and obtain timely payment. The position requires at least three years of experience in a healthcare or accounting environment, with an emphasis on HMO contracts, billing, and collections. An associate degree in business, accounting, or finance is required, or equivalent knowledge and skills gained through education, training, and experience. The role also requires proficiency with Microsoft Excel and accounting software, and experience with EHR and billing systems/software. Knowledge of HMO contracts and Medicare/Medicaid regulations is preferred; experience with PCC is also preferred. The work involves prolonged computer use and frequent standing or walking, reaching, pushing or pulling, talking or hearing, tasting or smelling, and lifting up to 50 pounds. Sitting and activities such as climbing, balancing, stooping, kneeling, crouching, or crawling occur occasionally. The usual noise level is low to moderate. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Requirements

At least 3 years of experience in a healthcare or accounting environment, emphasizing HMO contracts, billing, and collections.
Associate degree in business, accounting, or finance, or equivalent knowledge and skills obtained through education, training, and experience.
Proficiency with Microsoft Excel and accounting software.
Experience with EHR and billing systems/software.
Ability to creatively solve problems, work as a team player, stay organized, and be flexible.
Ability to read technical procedures and policy and procedure manuals.
Ability to present information effectively and respond to questions from managers and employees.
Ability to apply fractions, percentages, ratios, and proportions to practical situations.
Ability to solve practical problems and interpret written, oral, diagram, or schedule-based instructions.

Nice To Haves

Knowledge of HMO contracts and Medicare/Medicaid regulations.
Experience developing and delivering training on accounting procedures and rules.
Experience with multi-site coverage.
Knowledge and experience with PCC.

Responsibilities

Monitor HMO claims by reviewing admissions, verifying eligibility, reviewing case management software, and ensuring payer and claim forms are set up in patient records.
Pursue billing and collections promptly and effectively for assigned centers, including researching issues and processing adjustments and rebills as needed.
Identify reconsideration and appeal opportunities and coordinate with facility staff to fulfill audit requests.
Complete HMO Triple Checks with assigned centers to verify UB-04 claim accuracy and proper accounting of revenue; submit billing by the fifth business day and verify receipt by the seventh business day.
Follow PACS collections policy for HMO payers, report in a timely manner, and document collection efforts in patient billing records and healthcare software.
Partner with the Managed Care Department to maximize revenues.
Monitor and follow up on claims using insurance platforms and serve as an insurance provider portal expert.
Ensure revenue is properly booked and billed using exclusion worksheets.
Research denials and overpayments or underpayments for HMO claims.
Maintain knowledge of HMO contracts and changes, and educate and communicate contract information to team members.
Use provider manuals, cheat sheets, managed care resources, and information sheets to ensure accurate billing and collections that comply with HMO contract requirements.
Monitor case management software for current and ongoing authorizations and communicate outstanding authorizations to center leadership.
Maintain ongoing communication with center Administrators, Business Office Managers, and AR Resources.
Provide professional customer service and communication to PACS team members, vendors, and outside representatives.
Develop and maintain professional relationships with payer representatives to support timely collections.
Collaborate with the Director of Accounts Receivable on department initiatives and special projects.
Perform other duties as assigned.