Overview
This role manages the claims and billing processes, ensuring accurate and timely charge entry, clean claim creation, and billing. It involves aggressive and regular claim status follow-up through electronic and verbal communications, monitoring and handling claim rejections and denials, and managing appeals. The position also includes specialty-focused tasks.
Responsibilities
- Maintain knowledge of State and Federal billing and reimbursement guidelines, including third-party insurance plans, policy changes, contracts, and fee schedules.
- Oversee day-to-day billing operations, including:
- Reviewing professional Fee for Service and Federally Qualified Healthcare Centers (FQHC) claims for accuracy and proper coding.
- Preparing and submitting clean claims electronically or by paper in a timely manner.
- Confirming claim receipt status with payers within seven business days of billing.
- Managing designated work queues and reporting claims outside these queues to management.
- Reduce aged receivables through focused claim management:
- Escalate claims aged 45 days without adjudication to payer claims adjudication managers.
- Escalate unpaid claims over 60 days to management for review and collection decisions.
- Review Explanation of Benefits (EOBs) within five business days of posting for next billing actions.
- Handle rejected and denied claims according to department guidelines.
- Conduct bi-weekly claims status reviews with payers.
- Appeal denied claims with persistent follow-up and resolution efforts.
- Produce and distribute monthly patient statements when applicable.
- Maintain and follow up on patient payment plans when applicable.
- Collaborate with Front Office to ensure collection of patient responsibilities.
- Retrieve confirmation reports and verify claims and statement submissions.
- Review billing reports for errors and trends, reporting issues to management.
Requirements
- High School Diploma or equivalent required.
- Associate degree in Healthcare Administration or related field preferred.
- Certification in professional billing (CBC) preferred.
- Minimum of 6 years of healthcare billing and collections experience required.
- Experience with FQHC billing preferred.
- Knowledge of eClinicalWorks (eCW) preferred.
Working Conditions
- This is a remote position requiring a dedicated, quiet workspace.
- Must adhere to HIPAA and other privacy policies.
- Reliable high-speed internet connection required.
Physical Requirements
- Ability to communicate clearly and exchange accurate information consistently.
- Ability to remain stationary for extended periods.
- Frequent use of computer, keyboard, copier, fax machine, phone, and other office equipment.
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