The Medicare Billing and Follow-up Representative is responsible for the compliant, accurate and timely billing and follow-up of all hospital Medicare and Medicare Advantage Patient Accounts.

Essential Duties and Responsibilities

These duties and responsibilities described below represent the general tasks performed on a daily basis; other tasks may be assigned.

·         Submit Medicare/Medicare Advantage plan claims both electronic and paper claims (UB-04 and 1500) to the appropriate government and non-government payers

·         Submit shadow bill (Information only claims) to Medicare

·         Understand how to resolve Medicare/Medicare MA billing edits and/or warnings and billing edits that are identified in the Patient Accounting Billing System

·         Knowledge of working F.I.S.S.(Florida Institutional Shared System) in order to resolve Medicare claim issues

·         Keep abreast of Medicare/Medicare MA government requirements and regulations.

·         Understand ABN's and the requirements when and how to appropriately bill claims for resolution

·         Experience and knowledge with working the Medicare Quarterly Credit balance report

·         Experience in ICD-10, CPT-4 and HCPC professional terminology

·         Knowledge and understanding regarding the processing of the In-Patient lifetime reserved notifications, rules and regulations

·         Knowledge and understanding working MSP (Medicare Secondary Payer) files

·         Knowledge and understanding billing TPL (Third Party Liability) claims and conditional billing

·         Current knowledge of Medicare Transmittal, Change Requests and the ability to understand and interpret Monthly CMS News Updates

·         Understands LCD (Local Coverage Determination) and NCD (National Coverage Determination) and how it relates to medical necessity

·         Ability to navigate and fully utilize Medicare Fiscal Intermediary (Palmetto GBA) and CMS web sites

·         Understanding of the CMS Publication: 100-4 (Medicare Claims Processing Manual)

·         Ensures claim information is complete and accurate in order to maximize the clean claim rate resulting in claim resolution and payment for complex billing and payment issues

·         Analyze information contained within the Patient Accounting and Billing system to make decisions on how to proceed with the billing of an account.

·         Processes rejections by correcting any billing error and resubmitting claims to government and non-government payers.

·         Place unbillable claims on hold and properly communicate to various Hospital departments the information needed to accurately bill.

·         Process late charge claims in the event that charges are not entered in a timely fashion by Hospital Departments

·         Submit corrected claims in the event that the original claim information has changed for various reasons

·         Perform the billing of complex scenarios such as interim, self-audit, combined, and split billing etc.

·         Limit the number of unreleased claims by reviewing all imported claims and either billing or holding the claim for further review

·         Meet Billing and Follow-up productivity and quality requirements as developed by Leadership

·         Measured on high production levels, quality of work output, in compliance with established CRH's policy and standards

·         Review patient financial records and/or claims prior to submission to ensure payer-specific requirements are met

·         Keep abreast of payer-specific and government requirements and regulations

·         Follow up on unprocessed or unpaid claims until a claims resolution is achieved

·         Generates letters to insurance or patients as needed in order to resolve unpaid claim issues.

·         Works on and maintains spreadsheets by sorting/adding pertinent data

·         Analyze information contained within the billing systems to make decisions on how to proceed with the account.

·         Work independently and has the ability to make decisions relative to individual work activities

·         Identify comments in the billing systems by using initials and using approved abbreviations for universal understanding

·         Keep documentation clear, concise, and to the point, while including enough information for a clear understanding of the work performed and actions needed

·         Create appropriate documentation, correspondence, emails, etc. and ensure that they are scanned to the proper account for accurate documentation

·         Read, understand, and explain benefits from all payers to coworkers, physicians, and patients

·         Make phone calls, use the internet, and send mail to payers for follow-up on unprocessed claims, incorrectly processed claims, or claims in question

·         Develop relationships with customers/patients/co-workers in order to gather and process information or resolve issues in order to receive accurate reimbursement and optimize internal and external customer satisfaction

·         Post accurate adjustments as appropriate per billing policies and procedures, payer explanation of benefits, and the management directive

·         Maintain work procedures pertinent to the job assignment

·         Accountable for individual work activities

·         Resolve questions that arise regarding correct charging and/or other concerns regarding services provided

·         Complete cross-training, as deemed necessary by management, to ensure efficient department operations

Education: CRCS Certification and or College degree preferred in health care or business related field or High school diploma is significant with years of patient revenue cycle/process experience in lieu of college degree. Additional specialized training relevant to job responsibility.

Experience: 5 plus years in a Hospital setting with extensive background in hospital billing and follow-up functions.  Must exhibit very strong and/or been engaged in analytical and compliance issues.

Knowledge, Skills, and Abilities 

Technology: PC - Intermediate Microsoft Excel - Advanced Word - Intermediate Database - Epic HB – MedAssets Claims Management and Knowledge Source -  Intermediate Calculator - Advanced Data entry - FISS.

*Excellent communication skills

*Excellent written communication skills

*Demonstrated team skills

*Excellent analytical/accounting/statistical reporting skills

*Medicare and all Governmental Billing Rules and Regulations

Certificates, Licenses, Registrations

Applicants must be a Certified Patient Account Technician (CRCS) upon hire or within six months of the start date.