Billing and Collections Representative

Billing And Collections Representative

Under general supervision of the Supervisor of Billing, the Billing and Collections Representative completes daily billing and AR follow up for assigned scope, in accordance with established criteria. Includes the daily reconciliation of assigned reports and controls to ensure claims are billed accurately and timely. Coordinates follow up with providers, clinic, and hospital staff as needed. Serves as the first point of contact for customer calls and inquiries regarding billing and claim payment.

Every effort has been made to make this job description as complete as possible. However, it in no way states or implies that these are the only duties the incumbent will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or is a logical assignment to the position.

Resolves daily billed claim edits and rejections: target Clean Claim rate of 95% or greater:

• Resolution of Electronic Billing System (EBS) client, payer, and/or clearinghouse acceptance and rejection reports
• Monitor and follow up to identify and resolve discharged not final billed holds (DNFB)
• Process Balance Bill claims to next payer after primary/secondary claims are accurately adjudicated
• Accurate completion of UB04 and/or 1500 claim form/field requirements, by payer (condition, occurrence and value codes, etc.) for primary, secondary, and tertiary claims
• Accurately interpret payer specific Explanation of Benefits (EOB) and Remittance Advice (RA) to identify claim modification and/or special billing requirements
• Monitor and release claims to meet Timely Filing requirements
• Review/Resolve hold claims and release to billing w/in 24 hours
• Submit clean claims for outpatient & inpatient hospital services and Rural Health Clinics

• Combine claims as appropriate to ensure compliance with applicable billing rules and regulations, including but not limited to:

• CMS Payment Window Rule
• Series Claims/Recurring Services
• Packaged/Bundled Services
• Worker's Compensation
• Department of Transportation (DOT)
• Accident and Other Liability
• Attorney and/or Probate
• Balance Billing (secondary/tertiary payers)

• Resolves denied claims: target denial rate of < 2% of total net revenue. Identify and resolve recurring payer-specific claim delays.

• Authorization, Pre-Certification, and Referrals
• Other Billing Issues
• Medical Record Copies
• Credentialing Issues
• Coding
• Charge Capture
• Medical Necessity and/or ABN Issues

• Identify and resolve recurring provider/clinic-specific claim delays: registration demographic profile, eligibility and Iplan assignment, authorization/pre-certification/referrals, medical necessity and/or ABN, charge entry and coding accuracy.
• Performance Improvement Opportunities: Compiles information and contributes to the trending of Bill Holds and Denials for performance improvement by Provider, by Payer & by Reason/ Reason Code.
• Achieves daily targeted individual productivity and performance outcomes for: daily productivity, Clean Claim submission rate, & quality assurance.
• Provides backup as needed to the Scheduling and Registration staff in the Rural Health Clinic by answering phones, scheduling, and performing patient registration.
• Abides by the HMH Legal Compliance Code of Conduct.
• Maintains a safe work environment and reports safety concerns appropriately.
• Maintains confidentiality and appropriate handling of PHI.
• Performs all other related duties as required and assigned