Medicare Billing and Follow Up - 100% Remote
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The Medicare Specialist (MS) is responsible for the billing and follow up of Medicare accounts receivable. The MS is considered an expert in Medicare billing guidelines. This includes preparing and processing claims; clearing billing edits; claim validation and submittal; and receivable follow up to ensure that claims are paid timely, accurately, and compliantly. The MS will ensure that all claims billed are complaint with state and federal regulations related to the Medicare program, and all payments received by the Medicare program are correct. These skills are necessary in order to ensure any claim that leaves Methodist is compliant.
The MS must have a solid working knowledge of patient account receivable. In addition to billing Medicare guidelines, this includes knowledge of Patient Access Services/Admissions, Case Management, Medical Records Coding, Collections, Charge Review, Medicare payer systems (FSS), and post payment activities.
The MS must possess expert knowledge of the Medicare program; have the ability to partner with various hospital departmental counterparts, and the ability to communicate verbally and in writing.
The MS will follow general policy and procedures (i.e., Attendance, Dress Code, Call in Procedures, Levels of Authority, etc.) and must be willing to accept feedback from Management in a positive manner and implement improvements where indicated.
The MSII will be expected to interact with all the Corporate Business Office (CBO) sub-units and other hospital service areas on a daily basis. The MS will be expected to cultivate good business relationships to promote harmony and effective communication to resolve patient and billing concerns post care.
DUTIES AND RESPONSIBILITIES
- Is knowledgeable about operations and effectively communicates in writing or orally with customers, vendors, colleagues, and management to meet operational business needs. (EF)
- Communication is active, positive, and effective.
- Participates in action plans to meet departmental goals.
- Demonstrates SERVICE PRIDE standards.
- Demonstrates and supports the Methodist vision, mission and ICARE values statement.
- Attends department and sub-unit meetings. This includes preparing ahead of time and active reporting of issues as necessary to management. (EF)
- Partners with departmental vendors as needed to ensure claims are compliant and WIP is at departmental standards.
- Partners with hospital departmental counterparts to resolve claim issues.
- Follows levels of authority for posting adjustments, refunds, and contractual allowances. Posts adjustments accurately as stated on the Medicare RA or 835. (EF)
- Has working knowledge of the Medicare Electronic Data Interchange (EDI) process including 837 creation and submittal, Medicare Shared System processing and status locations, transmittal balancing, and 835 processing.
- Manages time effectively to report to work as scheduled; to meet quality and productivity standards; and to meet project due dates
- Understands and fully utilizes computer systems used in the technological stream of transmitting Medicare claims. Includes but not limited to: (EF)
- ADT and Patient Accounting systems (HBOC/Epic, etc)
- Billing Software/Scrubbers (Claims Administrator, Claims Master, etc.)
- Medical Necessity Software (PCA, etc.)
- Medicare FISS (Medicare Manager/FISS)
- Receivable follow up software (Receivables Work Station, Aeos, Epic, etc.)
- Imaging Software (HPF, etc.)
- Understands Medicare IPPS and OPPS including SNF, Psych, and Rehab payment methodologies, to ensure claims are compliant. This includes understanding the nature and resolution of claim edits such as CCI/NCCI, APC, and LCD/NCD. (EF)
- Fully utilizes system claim tools including primary and secondary claim scrubbers, claim editing software post initial bill, receivable software, and the Medicare shared system (FISS) to ensure all WIP is kept at department standards. (EF)
- Must be able to fully understand the Medicare remittance advice (RA) and all financial elements contained on the RA as well as the explanation of benefits (EOB) from other insurances. (EF)
- Ability to document accounts in a brief and concise manner, indicating resolution or steps needed for resolution. Documented comments should be fully understood by the next person who reviews the account. (EF)
- Exceed quality standards based on account reviews and feedback as provided by the Government Manager. This includes incorporating instruction/training into daily routines on an immediate basis. (EF)
- Understands Medicare payment classifications including but not limited to MS-DRGs, Outliers, APCs, Pass Through, and RUGs. Additionally, must understand the claim requirements related to payment such as occurrence/condition/value codes, ABNs, Modifiers, Transfers, Exhausted Benefits, Medicare as a Secondary Payer, and Credit Balances. (EF)
- Demonstrates understanding of daily tasks in how they impact department metrics including WIP, Cash, Credit Balances, and Agings. (EF)
- Demonstrates a working knowledge of ICD coding (procedure and diagnoses), CPT and HCPCS. (EF)
- Understands the Revenue Cycle (from a tactical perspective).
- Meets weekly productivity standards including maintaining personal WIP at departmental (EF)
- Responds to other departements when Medicare claim processing information is needed. This can include working with management to respond to internal audit, case management, Medical Records, etc. (EF)
- Responds appropriately, thoroughly and timely to patient related issues and/or questions. This can be requests from customer service call center, patient correspondence, or patient requests originating from other hospital departments or management. (EF)
- Independently utilizes available resources (electronic and print) to gain understanding of Medicare process and edits in order to resolve billing issues and work in progress (WIP): MAC website, UB04 Claim Editor, Medicare I/OCE editor, CMS website, etc. (EF)
- Uses educational tools to stay current with the Medicare Program. This includes attending local seminars, staff trainings, CMS webinars, alerts, notices, boot camps, etc.
- Participate in Claim and Software testing as needed for Software Updates, Business Profile updates or IT updates.
This position description is not intended to be all inclusive, and the employee will also perform other reasonably related business duties as assigned by the immediate supervisor and other management as required. The Houston Methodist Hospital reserves the right to revise or change job duties and responsibilities as the need arises.
High School Diploma or GED required. Some college or Associates a plus. Bachelor's in healthcare related field will be given preference.
Prior Medicare billing (claim generation and edit resolution) experience in a large hospital or enterprise setting required (minimum 5 years)
Medicare receivable follow up utilizing patient database (HBOC or EPIC) experience (3 years minimum)
CERTIFICATES, LICENSES AND REGISTRATIONS REQUIRED
Medical Coding certification preferred (CPC, CPC-H, CCA, or CCS)
Revenue Cycle certification preferred (CRCS/CPAT or other hospital billing certification)
SPECIAL KNOWLEDGE, SKILLS AND ABILITIES REQUIRED
- ICD-9CM/10; CPT/HCPCS coding knowledge required
- Strong customer service and analytical skills required
- Strong PC skills.
- Must be able to work with Excel (tables, lists, sorting, etc.)
- Excellent verbal and written communication skills in the English language
- Ability to follow-through and handle multiple tasks simultaneously
- Ability to work independently
Houston Methodist (HM) is one of the nation’s leading health systems and academic medical centers. HM consists of eight hospitals: Houston Methodist Hospital, its flagship academic hospital in the heart of the Texas Medical Center and seven community hospitals throughout the greater Houston metropolitan area. HM also includes an academic institute, a comprehensive residency program, a global business division, numerous physician practices and several free-standing emergency rooms and outpatient facilities. Overall, HM employs over 25,000 employees. Houston Methodist is supported by a wide variety of business functions that operate at the system level to help enable clinical departments to provide the best patient care and service in a spiritual environment.
In 2019 Houston Methodist and its physicians treated more than 6,333 international patients from more than 76 countries. Houston Methodist Global Health Care Services’ consulting and education divisions also provide advisory services and training and development to health care organizations around the world.
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