HMO Biller

Position Summary

The HMO Billing and Collections Specialist is responsible for recording all revenue, electronic claim submissions, and timely collection from all HMO payer sources.

ESSENTIAL DUTIES AND RESPONSIBILITIES

1. Monitors HMO claims by reviewing all HMO admissions, verifying eligibility, reviewing case management software, and ensuring payer and claim form is set up in patient records.

2. Ensures all billing and collections are pursued in a timely and effective manner for assigned centers, including researching, adjustments and rebills as needed.

3. Identifies reconsiderations, appeal opportunities, and collaborates and coordinates with facility staff to fulfill audit requests,

4. Completes HMO Triple Check with assigned centers to ensure UB-04 claim forms are correct and all revenue is accounted for and booked correctly. Ensures HMO billing is submitted by the 5th business day and verifies receipt of claims by the 7th business day.

5. Follows PACS collections policy for all HMO payers and reports in a timely manner. Documents all collection efforts in the patient billing record and healthcare software.

6. Partners with the Managed Care Department to maximize revenues.

7. Monitors and follows up on HMO claims by utilizing insurance platforms. Acts as an insurance provider portal expert.

8. Ensures revenue is properly booked and billed by utilizing exclusion worksheets.

9. Research denials and over/under payments for all HMO claims.

10. Maintains in-depth knowledge of all HMO contracts and contract changes. Provides education and communication to team members regarding HMO contracts.

11. Utilizes provider manuals, cheat sheets, managed care resources, and information sheets to ensure billing and collections are accurate and follow HMO contract requirements.

12. Monitors case management software for current authorizations, ongoing authorizations and communicate with center's leadership team when authorizations are outstanding.

13. Maintains constant communication with the centers Administrator, Business Office Manager (BOM), AR Resource.

16. Provides exemplary customer service and professional communication in all interactions with PACS team members, vendors, and outside representatives.

17. Develops and maintains a professional relationship with payer representatives to ensure timely collections.

18. Collaborates with Director of Accounts Receivable to champion department initiatives and special projects.

19. Performs other duties as assigned.

QUALIFICATIONS AND EXPERIENCE

Minimum of 3 years' experience in a healthcare or accounting environment with an emphasis on HMO contracts, billing, and collections. Knowledge of HMO contracts and Medicare/Medicaid regulations preferred. Ability to creatively solve problems, be a team player, be well organized and flexible. Experience in the development and training in accounting procedures and rules, and multi-site coverage an asset. Must be proficient with Microsoft Excel, accounting software, and experiencing EHR and billing systems/software.

EDUCATION

Associate’s degree in business, accounting or finance or equivalent knowledge and skills obtained through a combination of education, training, and experience.

SUPERVISORY RESPONSIBILITIES

This position does have supervisory responsibilities.