Under general supervision, is responsible for accurate and timely billing of all charge sessions for physician professional services to all third party payers and patient self-pay accounts. This includes reviewing the charge sessions / encounters, entry of charges into the accounts receivable system, corrections to third party claims, as needed, to ensure timely reimbursement for physician professional fees. Performs follow-up on aged receivables to determine cause of delayed payment and performs all necessary actions to resolve outstanding balance. Reviews initial denials to determine next steps while responding to billing concerns and working to prevent future denials by communicating with revenue cycle leadership about root causes. Participates in development of staff education and process changes relative to authorizations, coverage, and denials. Participates in quality assessment and continuous quality improvement activities. Complies with all appropriate safety and infection control standards. Performs all job duties and responsibilities in a courteous and customer-focused manner according to the Hurley Family Standards of Behavior.

Works under the supervision of a departmental director or designee who reviews work for accuracy and conformance to standard procedures. May direct the work of clerical employees of a lower grade.

Responsibilities

Performs necessary clerical tasks to expedite the preparation and processing of billing to all applicable third party payers and private pay patients. Performs point of service collection on insurance co-pays, deductibles, and pre-payment arrangements, for both the professional and facility component of visits. Documents, copies, and/or scans confirming documentation, such as insurance cards, identification cards, referrals, or authorization information received, into the billing software system.
Reviews all billings for accuracy and completeness. Within Professional Billing charge sessions and/or paper encounter documents, checks and verifies all third party identification numbers, diagnosis (ICD) and procedural codes (CPT/HCPCS), medical modifiers, chart documentation, financial class, insurance proration, etc.
Reviews denials and initiates appeal process, as determined by internal guidelines. Monitors and follows up on denials and appeals, determining if escalation to an internal or external source is necessary to resolve the balance. Resolves unpaid balances before payer timely claim or appeal deadlines expire.
Composes, summarizes, prepares, types, and edits reports, letters, memorandums, and other materials. When necessary, submits claim forms with attachments to appropriate insurance carriers to support services and audits.
Contacts appropriate Medical Center departments, physicians, organizations, and eligibility systems to acquire necessary information for patient / insurance billings and reimbursement. Ensures proper identification of health insurance, primary care physician and primary care physician approval. Obtains appropriate referrals/authorizations/precertifications for both the professional and facility component of visits.
Communicate as necessary with patients and/or guarantors via mail, email, and/or telephone to promote timely resolution of third party claims in order to minimize unnecessary customer/patient involvement in the billing/reimbursement process.
Reviews claims for proper linkage between HCPCS and ICD codes using tools such as CCI, NCD/LCD, or other carrier edits. Submits all third party claim forms with attachments to appropriate insurance carriers. Submits statements to patients for payment.
Performs the majority of daily tasks by accessing assigned billing software work queues for both claims processing and follow-up activities. Makes entries into the billing software system to reflect current billing status of each patient account worked and to ensure an audit trail of all account activity. Works to maintain a current status of assigned work queues.
Documents via system account activities, system actions, manual notes, and/or smart text options all account activities including but not limited to financial class changes, statement processing, transactions, account adjustments, claim corrections, patient interactions, etc.
Reviews, investigates, and corrects rejected claims. Rebills third party payer or patient. Notifies management of any issues or problems.
Initiate updates to patient registration information including demographic and insurance information as appropriate and necessary.
Acts as liaison among patients, third party payers, and the Medical Center with regard to billing issues. Interacts as necessary with SBO/Customer Service Team to assist in the resolution of billing related inquiries or questions.
Under direction of supervisor, performs advanced assignments such as training and special studies.
Performs other related duties as required. Utilizes new improvements and/or technologies that relate to job assignment.

Qualifications

High school graduate and/or GED equivalent.
Two (2) years of experience in physician billing to third party payers or successful completion of a medical insurance specialist program from an accredited educational institution including each of the following: CPT coding, ICD coding, medical terminology, anatomy and medical claims.
Working knowledge of authorizations, denial, and appeal processes.
Working knowledge of Microsoft Office Suite and Google Workspace.
Knowledge of billing procedures for third party payers.
Knowledge of medical terminology, procedure coding, diagnosis coding and appropriate modifier usage.
Ability to work productively and efficiently in a remote or in-office work environment.
Ability to communicate effectively both orally and in writing.
Ability to conform to departmental performance standards.
Ability to establish and maintain effective working relationships with physicians, superiors, co-workers, other Medical Center employees, patients, third party payers and the general public.