Medical Billing Specialist: Revenue Cycle Operations

Primary Duties and Responsibilities

• The Specialist is responsible for resolving inquiries related to claims, eligibility, and authorization and working with multiple parties to ensure records are up to date.
• The Specialist will ensure first-call-resolution standards are followed and will refer and follow-up as per Hoag guidelines.
• Ensure accuracy, reports issues, and works to resolve.
• Ensure compliance and regulatory guidelines and health plan requirements are met.
  Documents actions taken following HIPAA guidelines.
• May assist in providing customer service, member services, and others in working with providers/billing offices when needed.
• Assist in identifying and reporting issues working with the management team to help minimize re-work and address front-end process issues.
• Performs other duties as assigned.

Revenue Cycle

• May also maintains databases, audit information and works with patients to process patient payment.
• May follow up with insurance companies on outstanding or unpaid claims, create/send statements to patients.

Clinic MSO 

• The Claims Billing Specialist handles 35-40 calls daily from healthcare providers, health plans, billing companies, and members on inquiries related to claims, eligibility, and authorization
• Document all incoming calls following HIPAA guidelines in handling patient data 
• Support the claims department by preparing claim receipts and correspondences received in the Hoag Clinic MSO mailroom 
• Assist with daily pick-ups and distribution of mail and correspondences from dedicated post office boxes, fax machines, e-fax, secure file transfers, as well as sending provider EOBs, member letters, misdirected claims, and other letters sent by the Claims team 
• Interact in a positive and collaborative manner with internal and external partners especially in demanding and tense situations with providers and patients exhibiting a caring, empathetic, and patient attitude 
• Support the claims team in implementing initiatives in improving claims processing efficiency 
• Assist in provider customer service, member services, health plan, and other customers including making and answering phone calls to providers/billing offices when necessary, based on team guidelines 

Education and Experience Required:

• High School Diploma or equivalent 
• 1+ years of experience in medical claims/billing processing or claims customer service in a health plan, medical group, or IPA environment, knowledge of HMO/managed care regulatory guidelines
• Proficient in Microsoft Word, Excel, Typing/Data Entry

Revenue Cycle

• Experience in and knowledge of all medical billing protocols including HCPCS, ICD-10, and CPT codes as well as EMR system experience

Preferred:

Revenue Cycle

• Experience with Epic Tapestry CRM system and in claims adjudication; Working knowledge of regulatory guidelines in managed care (Title 22, AB1455, AB1203, AB1324, AB72, CMS guidelines, COB guidelines, etc.), claims processing, code categories (CPT, ICD, etc.)

Clinic MSO

• Experience with Epic Tapestry CRM system, 1 year of experience in claims adjudication

License Required:

N/A

License Preferred:

N/A

Certifications Required

N/A

Certifications Preferred

N/A