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

Essential Duties and Responsibilities

Duties and responsibilities described represent the general tasks performed on a daily basis, but not limited as 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 b illing edits and/or warnings and billing edits that are identified in the Pat i ent 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 inform ation 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 resubmit t ing claims to government and non-government payers .

+ Place unbillable claims on hold and properly communicate to va rious 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 c la im 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 rev i ewing 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 leve ls , 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 requiremen ts are met

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

+ Follow up on unprocessed or unpaid c l aims unti l a c l aims 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 i ndividual work activities

+ Identify comments in the billing systems by using in i tials 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 bill i ng 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

+ Report potential or identified problems with systems , payers , and processes to the manager in a timely manner .

Education and Experience

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.

Certificates, Licenses, Registrations

Applicants must be a Certified Revenue Cycle Specialist (CRCS) upon hire or within twelve months of the start date.