Medical Billing Specialist: Revenue Cycle Operations

Hoag•Costa Mesa, CA

About The Position

Description Primary Duties and Responsibilities The Specialist is responsible for resolving inquiries related to claims, eligibility, and authorization and working with multiple parties to ensure records are up to date. The Specialist will ensure first-call-resolution standards are followed and will refer and follow-up as per Hoag guidelines. Ensure accuracy, reports issues, and works to resolve. Ensure compliance and regulatory guidelines and health plan requirements are met. Documents actions taken following HIPAA guidelines. May assist in providing customer service, member services, and others in working with providers/billing offices when needed. Assist in identifying and reporting issues working with the management team to help minimize re-work and address front-end process issues. Performs other duties as assigned. Revenue Cycle May also maintains databases, audit information and works with patients to process patient payment. May follow up with insurance companies on outstanding or unpaid claims, create/send statements to patients. Clinic MSO The Claims Billing Specialist handles 35-40 calls daily from healthcare providers, health plans, billing companies, and members on inquiries related to claims, eligibility, and authorization Document all incoming calls following HIPAA guidelines in handling patient data Support the claims department by preparing claim receipts and correspondences received in the Hoag Clinic MSO mailroom Assist with daily pick-ups and distribution of mail and correspondences from dedicated post office boxes, fax machines, e-fax, secure file transfers, as well as sending provider EOBs, member letters, misdirected claims, and other letters sent by the Claims team Interact in a positive and collaborative manner with internal and external partners especially in demanding and tense situations with providers and patients exhibiting a caring, empathetic, and patient attitude Support the claims team in implementing initiatives in improving claims processing efficiency Assist in provider customer service, member services, health plan, and other customers including making and answering phone calls to providers/billing offices when necessary, based on team guidelines Qualifications Education and Experience Required: High School Diploma or equivalent 1+ years of experience in medical claims/billing processing or claims customer service in a health plan, medical group, or IPA environment, knowledge of HMO/managed care regulatory guidelines Proficient in Microsoft Word, Excel, Typing/Data Entry Revenue Cycle Experience in and knowledge of all medical billing protocols including HCPCS, ICD-10, and CPT codes as well as EMR system experience Preferred: Revenue Cycle Experience with Epic Tapestry CRM system and in claims adjudication; Working knowledge of regulatory guidelines in managed care (Title 22, AB1455, AB1203, AB1324, AB72, CMS guidelines, COB guidelines, etc.), claims processing, code categories (CPT, ICD, etc.) Clinic MSO Experience with Epic Tapestry CRM system, 1 year of experience in claims adjudication License Required: N/A License Preferred: N/A Certifications Required N/A Certifications Preferred N/A

Requirements

High School Diploma or equivalent
1+ years of experience in medical claims/billing processing or claims customer service in a health plan, medical group, or IPA environment, knowledge of HMO/managed care regulatory guidelines
Proficient in Microsoft Word, Excel, Typing/Data Entry
Experience in and knowledge of all medical billing protocols including HCPCS, ICD-10, and CPT codes as well as EMR system experience

Nice To Haves

Revenue Cycle Experience with Epic Tapestry CRM system and in claims adjudication
Working knowledge of regulatory guidelines in managed care (Title 22, AB1455, AB1203, AB1324, AB72, CMS guidelines, COB guidelines, etc.), claims processing, code categories (CPT, ICD, etc.)
Clinic MSO Experience with Epic Tapestry CRM system
1 year of experience in claims adjudication

Responsibilities

resolving inquiries related to claims, eligibility, and authorization
working with multiple parties to ensure records are up to date
ensure first-call-resolution standards are followed
refer and follow-up as per Hoag guidelines
ensure accuracy, reports issues, and works to resolve
ensure compliance and regulatory guidelines and health plan requirements are met
documents actions taken following HIPAA guidelines
assist in providing customer service, member services, and others in working with providers/billing offices when needed
assist in identifying and reporting issues working with the management team to help minimize re-work and address front-end process issues
maintains databases, audit information and works with patients to process patient payment
follow up with insurance companies on outstanding or unpaid claims
create/send statements to patients
handles 35-40 calls daily from healthcare providers, health plans, billing companies, and members on inquiries related to claims, eligibility, and authorization
document all incoming calls following HIPAA guidelines in handling patient data
support the claims department by preparing claim receipts and correspondences received in the Hoag Clinic MSO mailroom
assist with daily pick-ups and distribution of mail and correspondences from dedicated post office boxes, fax machines, e-fax, secure file transfers, as well as sending provider EOBs, member letters, misdirected claims, and other letters sent by the Claims team
interact in a positive and collaborative manner with internal and external partners especially in demanding and tense situations with providers and patients exhibiting a caring, empathetic, and patient attitude
support the claims team in implementing initiatives in improving claims processing efficiency
assist in provider customer service, member services, health plan, and other customers including making and answering phone calls to providers/billing offices when necessary, based on team guidelines