Ensure that North Oaks Health System maintains a standardized process and efficiency in obtaining revenue while adhering to billing, coding, collection, and compliance guidelines.
Prepare the daily processed insurance claims for submission to the appropriate payer by maintaining the payer specific edits.
Review held claims on a daily basis to ensure that the claim issues have been resolved, and the claim can be released for submission to the appropriate payer.
Prepare hardcopy/paper claims for mailing, along with all supporting documentation as required.
File/re-file denied/pended/suspended claims to the appropriate payer with appropriate documentation as needed.
Analyze and process claims that are returned through the mail.
Request medical records from the Health Information Management department and/or print the medical records from the system.
Prepare and analyze Corporate Invoices ensuring that charges and/or adjustments are accurate.
Analyze and resolve unpaid corporate accounts by contacting the client to ensure timely reimbursement.
Work with the Credentialing Area to ensure that all providers and/or departments are put on credential claim hold when they are not fully credentialed with the payors.
Work with Coders on services that require a higher level of coding expertise, such as, surgical procedures, anesthesia charges, etc.
Work with clinic management to resolve claim edits and denials.
Keeps supervisor/manager apprised of matters regarding billing, coding, collections and compliance.
Stays abreast of Charge Master functionality as it pertains to missing charges, audits, etc.
Must have an in-depth understanding of charging, coding, billing and reimbursement, as it pertains to claims, follow-up, reimbursement, credit balances and compliance guidelines.
Maintain a current working knowledge of the CMS 1500 billing guidelines, CPT codes, HCPCS codes, Modifiers, ICD-10 Diagnosis Codes, Correct Coding Initiative (CCI) edits, Medically Unlikely edits, and Medical Necessity edits that are needed to ensure proper billing, collections and compliance guidelines.
Maintain assigned WQ's and adhere to the deadlines that are set forth in the completion of said WQ's.
Analyze the Account, Charge Router Review, Claim Edit, Credit, Follow-Up, Guarantor, Remittance, Retro Review, and/or ROI WQ's resolving all open issues.
Call and/or write patients, employers, clients and/or third-party payors for additional information needed to file, process and/or resolve claims.
Maintain a communication log that documents conversations with Medicare and Medicaid to remain compliant with CMS guidelines.
Research and determine the necessary actions needed to resolve denied claims/charges listed on a payor explanation of benefits or remittance advice.
Contact Medicare, Medicaid and or other third-party payors to obtain status on claims where a response and/or payment has not been received.
Respond to telephone, written and/or CBO Support inquiries from patients, physician offices, insurance companies or departments promptly.
When necessary, obtain, verify and update guarantor/patient demographics and/or coverage/insurance information and eligibility.
Maintain, analyze, distribute and resolve faxes received.
Analyze credit balances on accounts and take the appropriate action(s) needed to resolve the credit balance.
Analyze and process credit balances that meet the guidelines outlined in the Escheatment legislation.
Manual and electronic posting of payments and/or adjustments from patients, third party payers, collection agencies, etc. to the appropriate accounts receivable, general ledger and/or INFOR on the same business day of deposit
Work with HB staff in the posting and/or adjusting of professional and hospital payments received in said bank accounts ensuring that all monies are accounted for and posted.
Download bank ACH payments on a daily basis, multiple times per day, ensuring that all deposits are accounted for.
Reconcile Infor Daily
Maintain daily manual check log ensuring that all checks are accounted for and posted.
Process NSF and/or stale checks according to processing guidelines.
Analyze unidentified payments and determine the appropriate application of such funds.
Produce End of Month payment posting reports
Ability to work under stress and to meet imposed deadlines.
Maintains and demonstrates a positive working relationship with the various levels of staff.
Attend department staff meetings and participate in work groups and committees.
Communicate effectively by expressing ideas clearly, actively listening and following the appropriate channels of communication.
Demonstrate a responsiveness to others ensuring complete follow-up on matters requiring additional attention.
Maintain a professional demeanor and confidentiality.
Enhance professional growth- and job-related development through in service meetings, educational programs, conferences, etc.
Perform other duties as assigned.
Follow North Oaks Health System compliance program and federal and state regulatory guidelines.
Minimum of one year experience and working knowledge of clinic/hospital billing, consisting of collections, reimbursement, customer service, and/or insurance verification OR completion/certification of billing/coding course required.
High school diploma or equivalent, required.
Requires manual dexterity sufficient to operate keyboard, telephone, copiers, and such other office equipment as is necessary.
Vision must be correctable to 20/40, and hearing must be in the normal range for telephone contact.
It is necessary to view and type on computer screens for long periods.
Work may also require sitting for long periods of time as well as stooping, bending and stretching for files, supplies, or other materials.
Working knowledge of the CMS 1500 billing guidelines, CPT codes, HCPCS codes, Modifiers, ICD-10 Diagnosis Codes, Correct Coding Initiative (CCI) edits and Medical Necessity edits that are needed to ensure proper billing, collections and compliance guidelines.
Must have an understanding of charging, coding, billing, and reimbursement.
Ability to work under stress and to meet imposed deadlines.
Basic knowledge of government and other payer coding, billing and collection rules and regulations.
Must possess a working knowledge of billing and coollections guidelines.
Must be able to deal with physicians, other health care practitioners, staff, patients and patients' representatives in a professional and tactful manner.
Must be able to function efficiently and professionally under occasional high stress conditions.
Must possess exceptionally good organizational skills.
Safeguard and preserve confidentiality at all times.
Must be knowledgeable in the procedure for release of medical records.
Discussions with others, whether in the office, hospital or community, are to be conducted exercising the utmost discretion with patient confidentiality in mind.
Must be highly motivated and, under general supervision, work independently on routine work; Supervisor, Assistant Manager and/or Manager is available to give advice and instructions or new or routine tasks.
Must also be able to function amiably and productively as part of the overall health care team.
Preferred completion of a medical billing and coding program.