Biller Denial Management Specialist

Billing Claims Specialist

The position bills claims to HMO's, Blue Cross Plans, Medical Assistance, and Medicare using standard hospital UB04's and 1500 forms through electronic claim transmission and paper in HIPPA compliant format. Reviews registrations for complete information obtained by registration to ensure accurate billing. Reviews all claims for accurate departmental charges before billing. Contacts insurance companies by telephone and internet for up to date billing procedures. Contacts physician's offices by telephone for billing information. Performs a variety of duties relating to interfacing with insurance professionals (Hospital Insurance Provider Representatives) and other departments within the Medical Center. Performs a variety of duties relating to the processing of data for billing purposes.

Minimum Requirements

Education:

1. High School graduate or equivalent.
2. Graduate of an approved medical secretarial Associate Degree program preferred and / or minimum of 2 years of related experience.

Experience:

1. Relevant experience in a related position which has provided the applicant with strong working knowledge in HIPPA compliance coding and billing.

Knowledge, Skills, Abilities:

1. Demonstrating knowledge in HIPPA compliant ICD-10 CM Diagnosis and procedure codes, CPT-4 codes, billing HIPPA compliant claims electronically on standard hospital forms or (alternatively).
2. Must have working knowledge and proficiency in computer operation.
3. This individual must be able to work as a team member with job sharing. Good communication skills to initiate communication to Mount Nittany Health System staff and insurance professionals regarding charges, coding and diagnosis problems.
4. Must have an understanding of the UB04 and / or 1500 forms and the procedure for review of CPT – 4codes, combined batteries, HIV charges requirements to release information, and review of revenue codes for HCPCS entered by Medical Records following HIPPA compliant formatting.
5. Possess thorough knowledge of claims submission process.
6. Must have knowledge of the assigned third parties' billing requirements:
1. Medicare
2. Medicaid
3. Blue Cross
4. Commercial
5. HMO
6. MVA
7. OVR
8. MH/MR
9. Worker's Compensation
7. Knowledge of specific medical and Health System billing applications, i.e., Medicare, Medical Assistance, Blue Cross Plans and HMO's is preferred.

License/Certification/Registration:

1. None required.

Supervision Received:

Receives general supervision from the Supervisor, Patient Billing.

Supervision Given:

None.

Responsibilities

Essential Functions

1. Billing responsibilities:
1. Coordinates outpatient coding for Medicare, Blue Cross, Medical Assistance, HMO's, and Commercial Insurance accounts.
2. Reviews registration information for accuracy.
3. Enters the coding into the system in preparation for electronic and hardcopy claims submissions following HIPPA guidelines.
4. Reviews patient bills for reasonableness prior to billing.
5. Ensures required signatures are obtained before processing.
6. Understands and utilizes reports for review of internal information for errors in preparation for electronic claims submission and make any corrections associated with this report.
2. Processes accounts for electronic claims submission to various insurance carriers.
1. Downloads conversion of claim files and submits claims for processing.
2. Performs Claims Edits, Back Ups and Error Reports.
3. Reviews CPT-4 codes, combined batteries, HIV charges, and revenue codes for HCPCS entered by Medical Records following HIPPA compliant formatting.
3. Reviews bulletins and other material pertaining to changes and the weekly review of voucher reports, insurance reports, and electronic billing reports.
1. Ensures any change is implemented by the correct date and stays current on any billing changes that are listed in bulletins.
2. Processes adjustments.
3. Assists in the preparation of forms, statistics, records, etc. as required.
4. Reviews vouchers for follow-up transactions.
5. Verifies that the correct balance is indicated under the proper insurance plan and/or patient balance, and the ability to make any corrections.
4. Interfaces with others for a mutual understanding and coordination of billing efforts.
1. Identifies problems within the department and makes recommendations to the Manager, Revenue Cycle.
2. Aids in the coordination of follow-up accounts by direct interfacing with insurance providers and other Medical Center staff.
3. Coordinates with registration and insurance verification clerk, UR staff for pre-certification and prior stay information, as well as the Case Management department for various areas in aiding the patient and complying with the Medicare policy for lifetime reserve days usage.

Non-Essential Functions

1. Performs related and miscellaneous duties as assigned.

About Us

Why Mount Nittany Health? At Mount Nittany Health, we provide high-quality patient care with a unique combination of the latest in clinical technology and compassionate medical professionals. We are committed to improving both the quality and availability of healthcare in our region and seek to hire only the best to support the communities we serve.