Billing & Claims Spec 2 MGBO

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Job Summary:

The Billing and Claims Specialist II manages claim processes, including accurate and timely claim creation, follow-up and correspondence with providers, insurance inquiries/correspondence. Processes paper and electronic claims to payers with complete information to satisfy and facilitate claim for payment. Responsible for working claim edits within Epic EMR and external claim scrubber edits prior to final submission. Also responsible for working claims rejected by payers, retro adjudicated claims needing review, as well as claims requiring an internal claim number for processing. Assists in clarification and development of process improvements and inquires. Assures payments from all sources are recorded and reconciled timely to maximize revenues and minimize denials. In addition, the Billing and Claims Specialist II assists other staff when issues arise, provides on the job education to staff when needed, and works with IT to troubleshoot issues and provide feedback for system improvement. Assists with training of new hires and monitoring of WQs assigned to Billing and Claims Specialist I's. This individual is cross trained to assist with workqueues owned by the Billing and Claims Administration Team as well as assisting Billing and Claims Administration Team Leads with special projects.

Core Responsibilities and Essential Functions:

Billing and Claims * Prepares and submits clean claims to third party payers either electronically or by paper. * Analyze, research, and independently resolve claim submission edits and payor rejections by obtaining information from the medical record and applying CMS rules and regulations, CPT coding guidelines, and departmental policies and procedures relative to claim submission. * Assist with training of new Billing and Claims Specialist I team members. * Works with clearinghouse, Change Healthcare, including appropriate follow-up and with support issues. * Focus attention on payers with complex billing requirements, accounts with high dollar balances, accounts approaching timely filing deadlines, and other advanced billing scenarios. * Coordinate process of patient eligibility through various third-party sources. * Provide support to provider sites for resolving Claim Edit issues. * Ensure all billing activity on accounts is documented and explained in the appropriate fields in the patient accounting system. * Identifies and resolves patient billing issues. * Denial and insurance follow-up management. * Attach documentation when required by payor for claim processing. * Consistently meet the current productivity and quality standards in processing daily electronic and/or paper claims to payers. * Issues adjusted, corrected and/or rebilled claims to third party payers. * Identify opportunities for system and process improvement. * Participate in the testing for assigned software applications, including verification of field integrity. * Follow Joint Commission and outside regulatory agencies mandated rules and procedures. * Maintains strictest confidentiality, adheres to all HIPAA guidelines/regulations. * Follow the Wellstars general Policy and Procedures, the Departments Policy and Procedures, and the Emergency Preparedness Procedures. * Accept the Claim Files daily, complete claims balancing in clearing house system, running weekly claims inventory reports. * Participate in all WMG practice go-live project claims setup testing and verification. * Participate in the daily claims credentialing related activities to include validating system setup forms, reviewing provider start dates and communicating this information to various stake holders. * Actively working claim submissions based on provider credentialed approvals from provider enrollment ensuring timely claims releases, adjustments, address validation, reporting, and escalations as needed. * Resolving and reviewing daily credentialing denials and NPI related rejections impacting AR aging, cash payments, and denials for those specified providers and practice locations. * Perform other duties and responsibilities as assigned. Professional Communication * Maintain confidentiality in matters relating to patient/family. * Assure patient privacy and confidentiality as appropriate or required. * Ensure minors have a parent or guardian listed as guarantor as appropriate. * Interact with patients/families with a variety of developmental and sociocultural backgrounds. * Provide information to patients and families to reduce anxiety and convey an attitude of acceptance, sensitivity, and caring. * Maintain professional relationships and convey relevant information to other members of the healthcare team within the facility and any applicable referral agencies. * Initiate communication with peers about changes and procedures. * Relay information appropriately over telephone, email, and other communication devices. * Interact with internal customers including HIM, Revenue Integrity, Patient Access, and Patient Financial Services in a professional manner to achieve revenue cycle department AR goals and objectives. Teamwork * Assist with special projects as assigned. * Work closely with other staff, co-workers, peers, and other members of the healthcare team to ensure a positive and effective work environment. * Report to appropriate personnel regarding assignments, projects, etc. * Initiate problem solving and conflict resolution skills to foster effective work relationships with peers. * Report to work on time and as scheduled. Professional Development * Attend staff meetings, in-services, and continuing education. * Assist in the development of indicators, thresholds, study methods, and data collection as assigned. * Respond to problems/opportunities to improve care/customer service. * Support involvement in system performance improvement initiatives. * Participate in and maintain competencies required for the position and specific unit/area(s) of assignment. Performs other duties as assigned Complies with all Wellstar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

High school diploma or Equivalent Required or Bachelor's Degree Preferred

Required Minimum License(s) and Certification(s):

All certifications are required upon hire unless otherwise stated.

• Certified Revenue Cycle Rep

Additional License(s) and Certification(s):

Required Minimum Experience:

Minimum 3 years medical billing experience, including knowledge of billing related reporting Required or working with medical payers including Medicare, Medicaid, and commercial insurance Required Working knowledge of CPT and ICD-10 coding systems. Required

Required Minimum Skills:

Knowledge of medical billing and collection practices required. Works well with deadlines and is results oriented. Good communication skills and customer service skills when interacting with patients. co-workers. physician practices. Strong problem solving and analytical aptitude. Excellent time management skills and capacity to work independently. Ability and willingness to exhibit behaviors consistent with standards of performance improvement and organizational values (e.g., financial responsibility, safety, partnership and service, teamwork, compassion, integrity, trust and respect.)

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