Medicare Specialist

Southeast. Always the right career direction.

Performs daily activities involved in the reimbursement process, i.e. claims filing/follow-up, entry of payments/adjustments, and follow-up on non-payment or payments below contracted fee schedule amount. Identifies any repetitive errors, either system or manual, take corrective action and document. Performs all tasks in a timely manner to ensure consistency in Accounts Receivables (A/R) totals and maintain a minimum of days in A/R.

Using internal and external computer systems and payer portals, work traditional Medicare and Medicare Advantage/Replacement inventory to full resolution.

• Works as part of a multi-disciplinary team to provide answers to inquiries and questions;
• Troubleshoot problems and provide information;
• Handle intervention or referrals with a professional and respectful customer service focus telephonically and/or in person;
• Provides a variety of support services in connection to the day-to-day operations in a health care environment;
• Maintains working knowledge of regulatory guidelines for billing;
• Ability to verify and load insurance coverages correctly for accurate billing;
• Provides claim submission for services provided at SEH;
• Work an resolve claim edits and errors daily;
• Provides follow up on claims which did not process correctly;
• Provides follow up with insurance companies or individuals to obtain accurate reimbursement;
• Understands the use of and navigation of Medicare’s DDE system and other governmental and commercial payer websites for claim status and corrections;
• Accurately determines Part A and Part B Medicare coverages and billing requirements;
• Reviews correspondence daily for appropriate follow up;
• Able to read and understand explanation of benefit files;
• Works closely with clinical team for accurate charges and modifiers;
• Verifies third party payer coverage;
• Coordinates authorizations when appropriate;
• Works closely with coding team for accurate submission on claim;
• Process and follow up on payer denials, consulting with various entities for completion;
• Understands hospice billing requirements and regulations;
• Research and resolve client billing problems or issues;
• Provide communication on the methods and principles used for billing to the customers and resolve concerns;
• Study contractual terms and conditions of payment to ensure payments are made consistent with terms;
• Conduct work functions to assist with late charge processes;
• Works closely with third party collection vendors for accurate payment records;
• Assist patients and their families with applying for financial assistance;
• Establish payroll deduction transactions;
• Make daily deposits to the bank;
• Ensure change fill requests are complete for department’s daily function;
• Work with patients to develop self-pay arrangements and payment plans when applicable;
• Post payments for both insurance and individuals;
• Review accounts and initiate refunds when applicable;
• Communicate self-pay balances for upcoming services and collect balances due;
• Work with accounting department for accurate financial documentation;
• Edit account for correct coverage documentation;
• Apply contractual adjustments in accordance with contracts;
• Print, scan and index correspondence to the appropriate account;
• Works closely with electronic payment process vendor for accurate posting and adjustments electronically;
• Oversee the electronic flow of the account through the billing process to include bad debt;
• Performs all other duties as assigned Direct Reports (supervised positions) None

High school diploma or equivalent

American Academy of Professional Coders (AAPC) Coding Certification (CPC)