Billing Specialist

Position Summary

Reporting to the Billing Manager, the Billing Specialist is responsible for ensuring the timely and accurate submission of claims, reimbursement follow-up, and denial management. This role ensures that claims are processed efficiently, payer trends are identified, and issues related to denials are addressed promptly. The position also contributes to the Continuous Quality Improvement (CQI) committee by identifying areas for improvement in billing processes. Additionally, the role involves staying updated with Managed Care Organization (MCO) updates and changes to billing requirements to maintain compliance and streamline operations.

Billing Specialist Level 1: This role focuses on ensuring the timely submission of claims, managing reimbursement follow-up, and addressing denials. It does not require the CPC credential but demands a thorough understanding of billing processes and payer requirements. 

Billing Specialist Specific Duties 

• Ensure timely and accurate submission of claims to payers, meeting OHI and MCO requirements.
• Review coder documentation for alignment with OHI and MCO guidelines, escalating discrepancies to the Billing Manager.
• Stay informed about MCO changes and billing requirement updates, ensuring compliance with payer guidelines.
• Manage payer denials by reviewing, correcting, and resubmitting claims, addressing denials in a timely manner.
• Monitor aging reports, focusing on delinquent accounts, and follow up with patients and insurance companies to resolve issues.
• Post payments, adjust contracts, and manage patient refund requests as needed.
• Provide excellent customer service by addressing billing inquiries from patients and insurance companies.
• Contribute to the CQI committee, providing insights on billing processes and suggesting improvements.
• Collaborate with the Billing Manager to track payer trends and implement solutions for faster claims resolution.
• Maintain proficiency in Billing Platform and EMR systems to ensure error-free claims processing.
• Ensure compliance with federal, state, and MCO regulations to guarantee reimbursement and minimize denials.
• Meet KPIs for billing efficiency, including claim resolution rates and denials management.
• Assist with manual charge input and other billing-related tasks as needed.
• Participate in training and meetings to stay current with billing policies and procedures.
• Use claims scrubbers to identify and correct errors before claims submission, reducing denials.
• Educate providers on proper documentation practices to align with coding and payer guidelines.

Billing Specialist Key Performance Indicators (KPIs) 

• AR 91+: Less than 15% of total AR.
• Denial Resolution: Ensure denied claims are addressed and reprocessed within 30 days.
• Monthly Scorecard: Maintain a passing rate of 80% or higher.
• Claims on Hold: Claims on hold should be worked within 10 business days.
• Claim Collection: Achieve a 90% collection rate on claims.
• Patient Refunds: Ensure refund requests are reviewed and sent to accounts payable within 5 business days.

Billing Specialist & CPC Education/Experience/Licensure    

• High School diploma or equivalent required.   
• Certification: CPC (Certified Professional Coder) is required for all CPCs.
• Medical Billing Certification is preferred or relevant years of experience.  
• One to two years of experience in a billing department, medical center, private physician’s office, or other applicable healthcare setting is required.  
• One to two years of experience in a Federally Qualified Healthcare Center is preferred. 
• Bi-lingual (English/Spanish) is preferred. 
• Proficiency in Microsoft Office 365 is required.  

Education/Experience/Licensure 

• High School diploma or equivalent required.
• One to two years’ experience in Healthcare or Call Center setting.
• Bilingual in Spanish and English preferred.
• Clinical certification (CMA, LPN, RN) preferred.
• Proficiency in Microsoft Office 365 is required.  

Benefits

• Medical, Dental, Vision and Life Insurance
• Flexible Spending Accounts with Medical and Dependent Care
• Voluntary Life Insurance
• 401(k) Salary Deferral and Match
• CME
• Paid Time Off 
• Paid Holidays
• Employee Assistance Program
• Employee Discounts
• Employee Referral Program