Medical Billing & Follow-Up Specialist

Key Responsibilities

• Contacts insurance companies daily via phone and payer portals to follow up on unpaid or denied claims and resolve reimbursement issues.
• Requests, submits, and reviews missing or corrected claim and patient information to support timely payment.
• Reviews CPT and ICD-10 codes to ensure claims meet payer requirements and drafts and submits appeals when necessary.
• Investigates payment delays and incorrect payments while maintaining detailed documentation of all actions in the patient accounting system.
• Communicates effectively with patients, providers, and insurance representatives and demonstrates strong attention to detail, computer proficiency, and written and verbal communication skills.
• Responds to incoming patient billing inquiries, providing clear, accurate information and resolving concerns in a professional and timely manner.

Essential Duties

• Has a thorough understanding of CPT, HCPCS & ICD-10 codes, HCFA and UB04 claim forms, DRG, insurance benefits including authorizations/referrals.
• Works daily with automated worklist, ATB and or assigned special projects in the patient accounting system to perform account audits of insurance and patient payments. Utilizes claims editing software and/or payor software to review claims history in order to address and resolve payment delays and/or incorrect payments.
• Maintains ability to read and comprehend all payors’ claims adjudication vouchers, explanation of benefits (EOB), or electronic remittance advice (ERA). Utilizes vouchers, EOBs, and ERAs to help confirm proper processing of claims and appropriate levels of reimbursement.
• Maintains a current and thorough knowledge of regulatory and procedural requirements related to the assigned account workload. Knowledge of applicable contracted payor documents including the contract matrix and state and federal regulations are required. Regulations include but are not limited to various reimbursement methodologies depending on the services billed and claims editing content.
• Contacts insurance companies or clients and uses proper negotiation or persuasion techniques to elicit payment promise or account resolution. When necessary, works with billers to perform re-bills or secondary billing. Calendars follow up collection calls and activities, according to existing procedures in order to meet personal productivity and departmental receivable goals.
• Performs appeals of insurance denials and/or incorrect reimbursement. Facilitates medical record documentation submissions when medical necessity is the basis for denial and other required documentation when expected reimbursement is not received.
• Processes all refunds, payment transfers and adjustments for account workload according to established Patient Financial Services (PFS) policies.
• Contacts patients when necessary to elicit claims and account resolution. Demonstrates good customer service and is knowledgeable when contacting patients.
• Identifies self-pay accounts and potential bad debt accounts for referral to outside agencies or attorneys for further collection efforts.

Other Duties

• Communicates regularly with PFS Supervisor or Manager regarding high-risk accounts.
• Responds timely (within 24 hours or next business day) to account inquiry calls from patients or insurance companies. Researches claims or account questions with responsible department and provides customers with requested financial information or refers them to other resources at National Jewish Health.
• Provides PFS Supervisor and reports weekly productivity statistics and reports workload fluctuations (backlog or shortages) in a timely manner. Maintains individual goals established by PFS management.
• Actively participates in team and departmental meetings by sharing ideas for improved work processes in PFS and performs as a back-up to staff absences and vacancies, as necessary.