Specialist, Billing

Billing Specialist

At Ovation Healthcare (formerly QHR Health), we've been making local healthcare better for more than 40 years. Our mission is to strengthen independent community healthcare. We provide independent hospitals and health systems with the support, guidance and tech-enabled shared services needed to remain strong and viable. With a strong sense of purpose and commitment to operating excellence, we help rural healthcare providers fulfill their missions.

The Billing Specialist, known as Revenue Cycle Specialist II with ruralMED, is responsible for planning, organizing, and implementing activities related to charging, billing, collections, and cash management functions.

This role requires strong, hands-on experience with critical access hospital (CAH), rural health clinic (RHC), and/or hospital/facility billing, including a deep understanding of the unique reimbursement methodologies, regulatory requirements, and payer guidelines associated with these settings.

The specialist ensures maximum reimbursement for services provided by utilizing expert knowledge of insurance rules and regulations, best practice workflows, and multiple billing systems. Additionally, this role serves as a key resource and mentor to other billing staff, particularly in complex hospital and rural billing scenarios. Compliance with all applicable federal, state, and local laws, as well as Ovation policies, is required.

General Requirements / Job Duties:

To perform this job successfully, an individual must be able to perform each essential job duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

Billing (Hospital & Rural Focus):

• Evaluate, coordinate, develop, and implement billing processes, with a strong focus on critical access hospital, RHC, and facility-based billing workflows
• Process electronic and paper claims accurately and timely, ensuring compliance with CAH reimbursement methodologies and payer-specific billing requirements
• Resolve clearinghouse and DDE claim errors and payer rejections, including those specific to hospital and rural facility billing
• Perform follow-up on underpaid or unpaid claims, particularly those involving complex hospital billing structures, cost-based reimbursement, and rural payer nuances
• Research and resolve issues impacting reimbursement, including medical necessity, coding discrepancies, and facility-specific billing requirements
• Review balances post-insurance to ensure proper adjudication based on hospital and CAH billing guidelines
• Resolve overpayments, including reconciliation of facility claims and cost-based reimbursements
• Process payer correspondence and take appropriate action using internal and external resources
• Maintain aging reports and proactively address accounts nearing timely filing limits
• Resolve denied claims using payer reconsideration and appeals processes, with emphasis on facility and rural claim denials
• Document all account activity thoroughly within the EHR system

Credentialing:

• Perform credentialing and re-credentialing for facilities and providers, ensuring alignment with hospital and rural billing requirements
• Maintain accurate provider and facility data for payer enrollment and reimbursement
• Ensure CAQH profiles are complete and current

Mentorship:

• Serve as a subject matter expert in critical access, RHC, and hospital billing
• Assist staff in troubleshooting complex billing issues, especially those related to facility claims and rural reimbursement models
• Mentor team members to improve efficiency and accuracy in billing processes
• Develop workflows and documentation specific to hospital and rural billing best practices

Reporting:

• Review and act on accounts receivable reports (DNFB, ATB, denials, clean claims, etc.), with attention to hospital billing performance metrics
• Prepare reports to address payer discrepancies, particularly those involving facility reimbursement issues

Other:

• Maintain accurate payer setup, including rules specific to hospital, CAH, and rural billing
• Stay current on CMS, Medicaid, and commercial payer regulations impacting facility and rural reimbursement
• Perform reimbursement analysis, including cost-based reimbursement and hospital payment methodologies
• Monitor third-party payer contracts to ensure accurate reimbursement
• Maintain proficiency in EHR, clearinghouse, and payer systems
• Communicate escalated billing or payer issues to leadership
• Participate in meetings, training, and continuing education
• Maintain professionalism and confidentiality at all times

Qualifications:

• High School Diploma required; Associate's or Bachelor's degree preferred
• Minimum of 2 years of medical billing experience required (5+ years preferred), with a strong emphasis on:
• Critical Access Hospital (CAH) billing strongly preferred
• Hospital/facility billing required
• Rural Health Clinic (RHC) billing preferred
• Proven experience working with facility-based claims, UB-04 billing, and payer reimbursement methodologies
• Strong knowledge of medical and insurance terminology
• Proficiency with Microsoft Office
• Knowledge of Nebraska payer rules is a plus

Working Conditions:

• Work from home with a stable internet connection, a dedicated workspace, and access to necessary equipment. Requires prolonged sitting and consistent communication via phone, email, and video conferencing.
• Remote work is expected 100% of the time unless otherwise agreed upon. This role requires access to confidential information and adherence to all privacy and security policies.