Provider Enrollment​/Billing Specialist - NOT REMOTE

Title

Provider Enrollment/Billing Specialist

Reports to:

Chief Financial Officer

Work week:
Hours not to exceed 40 per week

Wage classification:
Non-exempt

OSHA risk classification:
Low

This position exists to ensure the financial well-being of the PCHS organization through timely and accurate enrollment of all providers in insurance plans, filing of insurance claims and collection of patient accounts, and ensuring proper posting of payments into existing PCHS systems for medical, dental and/or behavioral health. This position may be responsible for any or all of the essential functions listed below in the electronic health record systems.

The expectation is this position will be onsite; no remote work available.

• Complete provider and group enrollment for all PCHS sites.
• Successfully implement the entire enrollment process for all providers, adhering to all timelines while maintaining strict confidentiality for matters pertaining to provider credentials.
• Coordinate credentialing data needed for enrollment.
• Effectively communicate with providers to ensure timely completion of outgoing and incoming applications.
• Maintain provider credentialing files electronically via provider enrollment software and CAQH.
• Complete revalidation of previously enrolled providers and groups.
• Communicate with insurance payers to resolve provider enrollment issues.
• Assist with credentialing tasks as needed or assigned.
• Develop a payor contact list and keep current.
• Develop and maintain a tracking list for provider enrollment.
• Help the billing department with any payment issues relating to PPO’s we contract with.
• Maintain Medicaid and Medicare Org numbers: do updates, etc.
• Maintain PPO sites for accuracy, changes, etc. This includes Availity, One Health Port, Medicare, etc.
• Provider Billing enrollment in all PPO’s plus Medicare/Medicaid/CAQH.
• Terminate providers from all payor sources when they terminate.
• Utilize enrollment email address to keep others in the loop.
• Work with provider to do all credentialing of payer sources when they come due.

• Collaborate with staff, providers, team members, patients, and insurance companies to get all claims processed and paid. Capable of performing all aspects of medical billing independently, including but not limited to, charge entry, posting insurance payments, rejections and follow-up.
• Assign correct diagnosis (ICD-10) and procedure (CPT) codes based on direction from providers. Must have specific knowledge of diagnostic and procedural terminology.
• Monitor aging to ensure timely follow-up of claims resolution, reduction of future denials, ensuring accurate payment, and escalation of issues to management as identified.
• Conduct insurance re-verification as needed through various tools and initiate billings to a new payer, reprocess the claim accordingly, or bill the patient.
• Research payer guidelines and write and submit appeals as appropriate.
• Manage collections.
• Complete VA prior authorizations.
• Review and appeal unpaid and/or denied claims.
• Prepare, verify, submit and track prior authorizations, including VA.
• Provide Good Faith Estimates to uninsured patients per federal regulation.
• Verify patient coverage and insurance benefits.
• Answer patient billing questions.
• Process insurance and patient refunds.
• Handle self-pay collection efforts on all unpaid accounts and submit to collections on a timely basis.
• Continuous data entry into state/federal/local reporting programs such as AKAIMS.
• Administrative responsibilities associated with meeting reporting requirements.
• Audit data when necessary and/or appropriate.
• Generate, process, and/or mail monthly statements.
• Knowledge of how to post in all electronic health record systems.
• Post payments, adjustments, and denials in systems as appropriate.
• Balance daily deposits to daily postings for all systems.
• Keep billing spreadsheets up to date, checking daily.
• Check allowables to ensure correct payment and account balances.
• Post zero pay correspondence as pertaining to: deductibles, copayments, and denials.
• Process credit card payments and balance credit card…