Managed Care/Commercial Account Specialist

Website College Medical Center

The Managed Care/Commercial Billing Specialist is responsible for the accurate and timely billing of claims to third party payor/non-government primary and /or secondary/tertiary payor and intermediaries. The biller monitors and/or corrects submitted claims to ensure accurate and prompt reimbursement of claims. This position performs a variety of duties and responsibilities of resolution on pending billing, rejections, denials, addressing billing issues/questions, reviewing patient accounts, and follow up timely. The Managed Care/Commercial Billing Specialist is expected to maintain the backlog to current, meet the 95% electronic billing, manage the billing edits, meet the required 95% of electronic billing, be familiar with clearinghouse edits, Medicare Prt B Billing, rebills requirements, update and maintain the billing DOFR matrix, aware of the current regulatory requirements, electronic and hard copy billing, and UB04 billing formats.
· 2 years of recent Medicare Billing experience – Acute Care Hospital
· Knowledge of medical terminology
· Understand UB04 claim form, CPT, HCPCS, ICD-9, and ICD-10 Codes
· Proficient with Microsoft Word and Excel computer applications
· High school diploma.
· Ability to deal effectively with patients, co-workers and other customers.
Ability to work independently

Sitting and Keying for long periods of time. Visual use of computer 80% of the day. Hearing acuity for telephone usage. Light lifting and filing.
Normal Office Conditions
(ALL duties listed below are essential to the job.)
· Employee’s conduct conforms to the Mission, Vision, Values, and Code of Conduct of College Medical Center.
· Values individual differences and demonstrates sensitivity to the cultural needs of others.
· Respects the rights, privacy and property of others, and maintains strict confidentiality.
· Effectively protects all health information from unauthorized access per HIPAA regulations and all applicable local and state laws.
· Exhibits good attendance and punctuality.
Provides appropriate notice prior to vacation/time off and notifies supervisor a minimum of two hours prior to shift when unable to come to work
· Observes allotted break and meal periods as prescribed by Hospital Policy and follows time card procedures by accurately writing in and out.
· Attends to personal affairs to avoid any interference with productivity.
· Adheres to the Dress Code.
· Demonstrates an understanding of their personal role in the case of fire/disaster and participates in Performance Improvement activities.
· Functions with an awareness of patient safety issues and applies basic principles of safety as identified within the facility.
Follows the occurrence reporting policy and procedure in reporting any potential safety issues.
  • Responsible for billing all third party payor/non-government primary and /or secondary/tertiary payor and intermediaries.
  • Completes daily assigned accounts on the worklist.
  • Performs timely billing, follow up review and ensures appropriate action is taken.
  • Ability to maintain an average of 100 claims worked daily.
  • Must have knowledge and understanding of contracts pertaining to billing requirements, current payor rates, understating of terms and conditions, as well as Federal and State requirements.
  • Reviews, corrects, and edits UB04 claim forms for electronic/hard copy claim submission in accordance with department billing policies, payor guidelines, and insurance contract requirements.
  • Communicates errors and/or missing information regarding patient’s insurance, charges, coding, etc. to the corresponding departments via the Claims with Missing Information/DNFB report regularly to management.
  • Has a strong understanding of the Rev Cycle Processes, from Patient Access (Auth & Admissions) through Patient Financial Services (Billing, collections), including procedures and policies.
  • Ability to communicate and provide timely feedback.
  • Ability to identify charge capture and missing charge.
  • Recommends denial edits to help mitigate denial issues
  • Reports New and Unknown billing edits to management for review and resolution.
  • Ability to trend issues and provide recommendation for resolution.
  • Takes ownership and the ability to follow through timely.
  • Reviews rejections, billing communication logs, identifies necessary corrections, and resubmits claims returned on electronic rejection reports daily.
  • Reviews and runs billing reports; Secondary Billing, DSG Deleted Claims, Mismatch Authorization, and other assigned reports.
  • Package claims by payor (Manual Billing).
  • Ability to produce reports and aging from billing system to provide feedback to management.
  • Reviews, adds and resolve billing Edits timely, no more than 72 hours.
  • Meet KPI of 95 % Electronic Billing
  • Understands DOFR and Contracts
  • Ability to perform complex mathematical calculations
  • Ability to net down accounts according to contract and/or policy and procedure.
  • Able to maintain Billing Matrix.
  • Document clearly and timely in patient account.
  • Responds to email within 24 hours.
  • Able to be independent and a problem solver.
  • Follows College Medical Center procedures for account management protocol.
  • Attends department specific training, in-services, staff meetings, etc. as requested.
  • Meet cash goal requirements and KPI’s expectations
Performs other duties as assigned.
Exhibits behavior that is courteous, compassionate, polite, friendly, and respectful towards patients, visitors, physicians, and co-workers and extends self to make patients, visitors, clinical staff, and peers feel welcome and respected.
Salary Rate: $20.73 – $25.91

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