Senior Billing Specialist

Job Description:

Summary

Responsible for handling all complex or past-due third-party billing claims for the purpose of securing reimbursement of services (Medicare, Medicaid, Managed Care); Serves as the “myUnity” SuperUser related to their specific payer expertise.

Responsibilities

1. Responsible for resolving claims (primary and related coinsurance) transferred from the Billing Specialist for which:

   • Payer did not pay expected reimbursement, especially if in conflict with contract terms
   • Claim aging is >90 days, or under 90 days and not submitted to payer and acknowledged
   • Claim is being audited for any reason (ADR, CERT, RAC, etc.)
   • Claim non-payment/under-payment needs appealed or resolved

2. Provides oversight and coverage for initial billing of skilled nursing facility/Anywhere Care claims to third party payers (Medicare, Managed Care, Commercial Insurance) or vendor Medicaid claims (Medicaid, Managed Care Medicaid and Medicaid Hospice) for multiple EverTrue sites, utilizing electronic claims submission

3. Serves as “myUnity” SuperUser for their specific Payer expertise to support Billing Specialist and to bring attention to Manager of Revenue Cycle Management (RCM) of any issues or enhancement ideas

4. Coordinates for all claim audits (ADR, CERT, RAC, National Audit, etc.) with Health Information Management Specialist (HIMS) to resolution of claim (Payment, Full Denial, Partial Denial); Coordinates information submission w/ HIMS for all appeals (including ADR appeals)

5. Completes monthly Allowance for Doubtful Accounts schedule for assigned payer(s)

6. Investigates and codes invoices sent to us as EverTrue responsibility under Medicare SNF Consolidated Billing rules

7. Completes applicable form to submit ll third-party payer refund requests for approval to Manager of RCM; Completes applicable form to request Accounts Receivable adjustments for approval to Manager of RCM

8. Reviews situations referred by the Billing Specialist(s) regarding transfer of resident responsible coinsurance to private pay account after all insurance payments have been processed if the resident responsible portion doesn’t make sense in comparison to the benefits verification information

9. Provides oversight and coverage for posting of ancillary charges in billing system

10. Month-end invoice coding for ancillary expenses related to short-stay and MCB services

11. Completes the Medicare Quarterly Credit Balance report for all communities

12. Maintains up-to-date technical knowledge of applicable Medicare/Medicaid/Managed Care/Anywhere Care billing rules and regulations via the CMS website, MAC website, etc.

13. Serves as a resource to residents and community billing staff for applicable insurance benefit related issues for their specific Payer expertise

Qualifications, Knowledge, Skills & Abilities

• High School diploma

• 3+ years of Medicare and Managed Care billing experience required

  • Applicable SNF/Anywhere Care Medicare and Managed Care experience required
  • Medicare/Insurance Appeals experience preferred

• Must possess specific payer expertise (e.g. Medicare, Medicaid, Managed Care, Anywhere Care)

• Proficient computer skills including Microsoft Outlook, Excel and Word are required

• Excellent communication skills

Physical Requirements and Working Conditions

The physical activities and demands described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job duties and responsibilities.

Lifting up to 30 pounds; Pushing/pulling 100 lbs. on wheels; A well-lighted and ventilated working area that has its own temperature control system (air conditioning and heat); The work will have some short notice requests, timelines for completion of tasks or reports and some major projects extending over months; Minimal exposure to infectious diseases and blood borne pathogens; Minimal exposure to chemicals and hazardous waste; Minimal exposure to outside weather conditions.

This job description is intended to describe the general nature and level of work performed by those assigned to this classification. This job description in no way states or implies that these are the only duties to be performed by those occupying this position. The job description and job functions described herein are subject to possible modification by EverTrue in accordance with applicable federal, state, and local laws.

Additional Information:

N/A