Commercial Billing and Collections Specialist

Insurance Billing Auditor

Supports the delivery of all insurance billing services by final/higher level auditing, correcting, and submitting claims. Ensures that billing services are timely, accurate, and allow for appropriate reimbursement. Conducts all claims-related follow up on payment delays, taking corrective action(s) to finalize account disposition and/or referring claims to the appropriate staff to ensure appropriate reimbursement in the timeliest manner possible. Conducts month-end close and cash posting responsibilities for all assigned locations. This position functions within a team environment and under general supervision.

Successful individuals manage a volume of work as established by PruittHealth productivity performance standards, are familiar with the rules and regulations of insurance billing and are skilled at problem solving and account resolution. They work well within a team and help foster an environment where continuous improvement in business processes and services is welcomed and recognized to build a high-performance culture via the standard PruittHealth responsibilities.

Key Responsibilities:

• Performs all billing and follow-up functions, including the investigation of payment delays resulting from pended claims, with the objective of receiving appropriate reimbursement based upon services delivered and ensuring that the claim is paid/settled in the timeliest manner possible.
• Works with assigned community services facilities' administrators and office personnel to manage relevant accounts receivable.
• Edits claim forms, using proper data element instructions for each payer, applying principles of coordination of benefits, and ensuring that correct diagnosis, and procedure codes are utilized.
• Submits insurance claims, including the maintenance of bill holds and the correction of errors, to provide timely, accurate billing services.
• Researches claim rejections, making corrections, taking corrective actions and/or referring claims to appropriate staff members for follow through to ensure timely claim resolutions.
• Conducts account follow up including the investigation of payment delays to appropriately maximize reimbursement based upon services delivered and ensuring claims are paid and settled in the timeliest manner.
• Applies knowledge of specific payer billing/payment rules, managed care contracts, reimbursement schedules, eligible provider information and other available data and resources to research payment variances, make corrections, and take appropriate corrective actions to ensure timely claim resolutions.
• Evaluates accounts, resubmits claims, and performs refunds, adjustments, write-offs and/or balance reversals, if charges were improperly billed or if payments were incorrect.
• Responds to inquiries, complaints or issues regarding patient billing and collections, either directly or by referring the problem to an appropriate resource for resolution.
• Participates in cross-training and job enlargement opportunities for major job responsibilities. Works with direct supervisor to identify minor set of responsibilities to develop and perform.
• Plans, organizes, and documents work to deliver business results by meeting or exceeding all individual operating metrics and service line agreement objectives.
• Follows all PruittHealth policies and procedures, state and federal laws and regulations and report violations and potential issues to his/her team leader as appropriate.
• Contributes ideas and actions towards the continuous improvement of Revenue Cycle processes.
• Adapts to learning new processes, concepts, and skills; Seeks and responds to regular performance feedback from team lead and provides upward feedback, as needed.
• Assists in orientation and appropriate training of team members, including helping cross-train peers in minor responsibilities and acting as a mentor to peers.
• Maintains positive work relationships with members of own and other teams to communicate effectively and ensure compliance with cross-team responsibilities.
• Carries out all duties with a "Commitment to Caring" attitude in accordance with PruittHealth's mission, vision, and philosophy.

Knowledge, Skills, Abilities:

• In-depth knowledge of various billing documentation requirements, the patient accounting system, and various data entry codes to ensure proper service documentation and billing of patient accounts.
• Knowledge of insurance and governmental programs, regulations and billing processes, commercial third-party payers, and/or managed care contracts and coordination of benefits
• Familiarity with medical terminology and the medical record coding process
• Knowledge of principles, methods, and techniques related to compliant healthcare billing/collections
• Familiarity with Insurance Claims management functions in non-acute settings
• Knowledge of Patient Management information system applications, preferably MatrixCare, as well as spreadsheet, word processing, and other basic Microsoft Office Suite applications
• Ability to execute strategy and communicate knowledge of business processes and enabling technologies, specifically in an Insurance Claims function
• Ability to comprehend and retain information that can be applied to work procedures to achieve appropriate service delivery
• Data entry skills (minimum 50-60 accurate keystrokes per minute)
• Strong accuracy, attentiveness to detail and time management skills
• Ability to conceptualize, plan, and implement stated goals and objectives
• Ability to work concurrently on a variety of tasks/projects in an environment that demands a high degree of accuracy and productivity in cooperation with individuals having diverse personalities and work styles
• Strong relationship-building and communication skills (verbal and written) in dealing with other team members and internal/external customers to expedite the patient accounting process
• Excellent ability to identify, prioritize, resolve and/or escalate complex problems promptly
• Ability to learn new applications/software systems effectively and efficiently
• Ability to communicate ideas both verbally and in writing to interact with others using on-on-one contact, formal presentations, and group discussions
• Ability to securely access and use protected health information (all medical record information) to perform the functions outlined as part of this position description

Minimum Education Required:

AA/AS in Accounting or Business (or Equivalent Education / Experience) preferred.

Minimum Experience Required:

Demonstrates experience and a proven track record in Insurance Claims in a medical setting of moderate size and complexity, information systems, and patient accounting applications, as typically acquired in 1-3 years of patient accounting / medical billing positions

Experience in month end close activities and reconciling cash received to the patient accounting system

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As an Equal Employment Opportunity employer, all qualified applicants will receive consideration without regard to race, color, religion, sex, national origin, disability, or veteran status.