The Government Billing Specialist is responsible for supporting management in the compliant and timely billing of pre-receivables and receivables and reconciliation of government billing issues. Requires working knowledge of the Revenue Cycle and the importance of evaluating and securing all appropriate government billing information to maximize reimbursement to the health system in a compliant manner. Specialists are responsible for working with multiple internal departments in issue resolution, resolving complex billing issues, managing correspondence with departments, and working continuously to reduce volume of accounts pending in the billing process.
1. Maintains the best practice routine per department guidelines working relevant work queues daily, documenting issues and follow-up with coding, revenue integrity, or other applicable departments in a timely manner per process with required documentation noted in system.
2. Reviews claims in the internal claims editor (RelayHealth ePremis), the claims clearinghouse (i.e., Center for Medicare and Medicaid Services (CMS) Return to Provider (RTP) or National Electronic Information Corporation (NEIC)) and/or on paper claims for accuracy and obtains additional information for processing.
3. Processes claims within timeliness and accuracy guidelines established for this position
4. Enables all claims rejected by the electronic claims management system (i.e., ePremis) are edited, corrected and processed as required by the system and specific payor guidelines
5. Monitors pre-billed accounts for timely correction and prompt resolution of appropriate billing requirements.
6. Identifies and initiates actions on charges and other information not on claim forms (CMS-1450: UB-04) but required for claim adjudication
7. Assists in continuously improving the aging of pre-billed accounts while monitoring and prioritizing accounts for billing within designated timely filing guidelines.
8. Provides system generated reports requested by management, as necessary
9. Reports recurring system problems – relating to the host system and the electronic claims management system – and payor issues to Government Billing Manager for review and resolution.
10. Reconciles billed account transmission records with clearinghouse acceptance reports to identify skipped or rejected claims for correction and resolution.
11. Communicates daily via the telephone or written communication with departments to obtain and provide all information to process and bill claims quickly and accurately.
12. Works with other departments (e.g. PFS, HIM, Case Management, etc.) to appropriately contribute to account resolution and manage pre-receivables.
13. Gathers data, summarizes and prepares reports for management and completes special projects as assigned.
15. Attends periodic meetings with payer representatives to discuss updated billing requirements and assist in developing action plan for implementation.
17. Adheres to all DeKalb Medical Center policies and procedures
18. Participates in continuous quality improvement activities and teams
19. Participates in supporting the organization’s vision, mission and values and adheres to DeKalb Medical Standards of Behavior
20. Performs other duties as assigned or requested
Minimum Education, Experience and Licensure Required:
· GED or high school diploma required.
· 3 to 5 years in an office clerical setting, with at least 1 year of experience in a hospital, payor or clinic business office setting
· Experience with automated patient accounting system required
· Experience with Medicare and Mediciard Services required
· Knowledge of healthcare billing, accounting, and general office procedures preferred
· Associate’s Degree program in Accounting, Business Administration or a related area of study or equivalent combination of education and work experience preferred
Skills, Knowledge and Abilities:
· Requires working knowledge of accounting, healthcare and general office procedures.
· Requires working knowledge of accounting principles that directly impact the accounts receivable, including debit and credit transactions; charge transfers; contractual allowances and adjustments; financial class changes.
· Requires working knowledge of the reimbursement and regulatory environment so as to ensure compliance regarding patient and insurance billing issues.
· Requires working knowledge of insurance regulations, managed care practices, regulatory agencies and alternative funding sources.
· May require assistance in completing appropriate follow through for complex accounts.
· Requires working knowledge of one or more Revenue Cycle processes.
· Requires excellent communication skills to clearly and concisely communicate verbally and in writing with peers, supervisors, payers, physicians, patients, other departments, etc.
· Ability to understand and enforce system credit, bad debt and charity policies and use of other financial assistance resources (e.g. bank loans, payment plans, etc).
· Requires strong problem solving skills to address payer and patient issues appropriately and know when to ask for assistance.
· Requires knowledge of different cultural group’s needs and desires, as well as customer service knowledge and skills.
· Requires moderate process improvement skills.
· Requires conflict management skills and time management skills.
· Proficiency in Microsoft Office products (e.g. Word, PowerPoint, and Excel) and website navigation for healthcare billing
· Demonstrates understanding of medical terminology
· Knowledge of CPT, HCPCS, ICD-10 coding procedures
· Working knowledge of Government, Commercial and Managed Care insurance carriers
· Performs skills and competencies as defined in orientation checklist and annual departmental competency checklist if applicable.
· Demonstrates and maintains competencies specific to patient population served.
Reports to: Government Supervisor
Positions Supervised: None