Job Description

Job Description

Job Description

Summary

Responsible for collaborating with Manager, Lead, claims staff and Health Plans to submit, monitor and track the FFS Billing process. Additionally, the candidate will be responsible for the accuracy and integrity of the claim’s submissions, tracking and appeals related to FFS Billing. Ensures interpretation and compliance with the appropriate DOFR’s, billing guidelines and HIPAA regulations, while developing and maintaining a working knowledge of the coding and provider billing regulations relating to claims submission. Prepares claims submission, appeals and reporting for monthly Finance Reconciliation. Works directly under the Supervisor of the Finance Auditing & Recoveries unit.

Duties and Responsibilities

· Run reports for FFS claims monthly.

· Cross train on other tasks and reporting requirements within the unit.

· Make sure claims are submitted to the Health Plan electronically monthly by EDI Unit.

· Work any rejections of the claims submitted electronically to Health Plan.

· Print onto CMS 1500 or UB04 forms to bill Health Plan when needed.

· Review payments for correct payment amount & Co-Pay.

· Review denials for services denied by Health Plan in error.

· Review denials for issues with the way the provider bills the claim to IPA/Client.

· Appeal any underpayments or inappropriate denials / denials made in error by Health Plan.

· Respond to request for additional information.

· Appeal payment denials and/or under payments identified to be in error.

· Research and resolve Health Plan request for refunds.

· Research and resolve and submission without a response from Health Plan.

· Report monthly of submitted, paid, denied services as well as issues with payments and provider billing.

Minimum Job Requirements

· High school diploma or GED.

· At least 5 years’ experience with medical billing or claims processing/examining.

· Certification in medical coding (CPC, COC, CIC, CPC-P, and CRC) or actively pursuing the above certification highly preferred.

Skill and Abilities

· Strong written and oral communication skills.

· Knowledge of medical coding, billing and the regulations and guidelines associated with it.

· Ability to analyze, interpret and prepare reports.

· Proficiency with Microsoft Office Programs; primarily Word, Excel and Access or higher; SQL knowledge is a plus.

· EZ-CAP® knowledge a plus.

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