Job Description

Job Description

Job Description

Description:

Summary of Role

The Billing Specialist is responsible for ensuring claims are resolved with third party payers in a reasonable time frame as defined by Revenue Cycle metrics. This includes working claims that fail payer rejection edits to resolve errors and submit corrected claims. Assesses errors quickly and effectively locating information to correct them and follows claims for resolution. Works with other areas in the Revenue Cycle to obtain information necessary to correct errors or supply additional information as necessary for claim adjudication. Remains up to date on regulatory requirements through informal and formal updates, including self-study of payer bulletins and guidelines. Performs other duties as assigned.

Key Responsibilities

• Verifies claims are received by the payer and follow up to obtain payment via phone calls, portal or website use. Calls patients or payers to obtain needed information to resolve an account balance when applicable.
• Reviews claim adjustment reason codes or explanations of benefits received by the payer to determine reasons for denial records.
• After denial review, evaluates next steps and follows up with the payer, drafting appeals or completing reconsideration forms as needed, in line with payer requirements.
• Obtains and sends medical records during the appeals process when needed to substantiate medical necessity.
• Maintains compliance with patient financial services policies and procedures.
• Escalates high-dollar accounts for a second-level appeal as needed and prioritizes research on accounts denied for no authorization, attempting to appeal or escalate to the Precertification department if a retro authorization is required.
• Apply creative problem-solving skills in order to overcome obstacles and resolve errors for claim adjudication.
• Coordinates with management and external departments to resolve unresolved accounts and potentially create process to redesign initiatives for long term root cause resolution.
• Maintains a comprehensive awareness of all insurance company updates including Federal and State guidelines.
• Meets productivity goals assigned by the Billing Manager.
• Completes special projects as assigned.

An individual in this position must be able to perform the essential duties and responsibilities listed above successfully. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions of this position.

The above list reflects the general details necessary to describe the principle and essential functions of the position and shall not be construed as the only duties that may be assigned for the position.

Education

• High School Diploma or equivalent

Required

• Three or more years of experience in healthcare billing.
• Experience using EPIC, Microsoft Office, and Payer Portal.
• Must be able to maintain a professional attitude and confidentiality.
• Strong oral and written communication, and time management skills
• Ability to work in a team environment
• Ability to multitask in a high volume, fast paced working environment.

Preferred

• Familiarity with commercial insurance guidelines and medical terminology
• Background in healthcare is a plus!

Physical and Mental Demands

Communication Skills

Ability to clearly explain billing procedures, insurance details, and payment options to patients, as well as effectively communicate with healthcare providers and insurance companies. Accurate documentation of billing information and patient interactions. Strong interpersonal skills to handle patient inquiries and resolve billing issues in a professional and empathetic manner.

Mathematical Skills

Proficiency in basic math operations for calculating charges, payments, and adjustments. Understanding of billing cycles, insurance reimbursement rates, and payment plans. Ability to perform reconciliations and handle financial discrepancies. Ability to analyze billing data, identify trends, and detect errors or inconsistencies.

Judgement and Decision Making

Ability to identify billing issues, investigate causes, and implement solutions. Prioritizing tasks based on urgency and importance. Evaluating complex billing situations, making informed decisions, and considering the potential impact on patients and the clinics. Ensuring all billing practices comply with legal and regulatory standards, maintaining patient confidentiality, and handling sensitive information responsibly. Ability to work under pressure, meet deadlines, and handle multiple tasks simultaneously.

Software and Technology

Skilled in using medical billing software and electronic health records systems. Familiarity with coding software and tools. Accurate and efficient data entry skills for processing patient information, billing codes, and insurance details. Ability to learn and adapt to new technologies and software updates. Proficiency in using office software for documentation and reporting.

Work Environment

Shifts are Monday - Friday between 7:30 AM – 5:00 PM. This position will report to the OAW Pewaukee Clinic and will eventually have the flexibility to be remote. The noise level in the work environment is usually moderate. Must be able to lift, push, pull up to 50 lbs.

Equal Employment Opportunity

OAW provides equal employment opportunity to all applicants and employees. OAW disapproves of, and will not tolerate, unlawful discrimination against any applicant or employee because of race, color, national origin or ancestry, gender (including pregnancy, childbirth, or related medical conditions), gender identity, age, religion, disability, family care status, veteran status, marital status, sexual orientation, or any other basis protected by local, state, or federal laws.

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