Billing & Claims Specialist
Fast Growing Financial Management Agency
Job Description
Job Description
List of Duties/Outcomes – Billing/Claims Specialist
1. Weekly preparation & submission of NC Innovations Waiver claims to the local public Health Plan/MCO ( Managed Care Organization )
2. Weekly post-submission processing for Innovations through the HHA.eXchange to resolve problematic or non-exported claims. HHA.eXchange is EDI processor that aggregates and processes EVV ( Electronic Visit Verification ) claims for Health Plans/MCO.
3. Weekly claims posting & work any denials or partially denied claims ( Status Report by 5 th of following month )
4. Semi-Monthly CAP Batching EVV ( Electronic Visit Verification ), non-EVV, and Attendant Nursing Care/Registered Nurse Claims with CAP ( Community Alternatives Program ).
5. Monthly Batching of Financial Management Entity claims
6. The development and implementation of processes and guidelines to ensure organizational best practices in the submission, review, and resubmission of claims
7. Monitor, Review, and complete follow-up for any claim denials or partially paid claims
8. Interact with, train and provide guidance to Agency staff to ensure proper submission and processing of claims
9. Development of billing protocols
10. Review of all Innovations and Community Alternatives Program 837/835s, RAs, and determine resolution strategies
11. Ensuring timely and accurate claim settlement for members and beneficiaries.
12. Completion of a Monthly Claims Reconciliation Report
13. Makes recommendations for organizational processes to improve claims submission and processing
14. Provides a monthly update to Agency Executive Team outlining claims status for the prior month and recommendations for organizational improvement.
15. Other duties may be necessary as the agency and position expands under the financial guidance of the CFO.
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