EDI Billing Specialist

SCOPE / GENERAL PURPOSE OF JOB:

Directly responsible for timely and accurate daily claim submissions, claim reconciliation to ensure all claims were accepted at the Clearinghouse and file maintenance functions associated with Allscripts Misys Tiger, Allscripts Pro PM and Practice Insight/e-Solutions software in accordance with RC Billing standards and Reimbursement policy and procedures, to include but not limited to patient statements/EPS, claim submissions (electronic and paper), claim reconciliation and file maintenance.  Responsible for seeking resolution to problems relating to timely and efficient claim submissions while ensuring excellent communication between the AR department, CBO management, Revenue Cycle IT Department and the Revenue Cycle Credentialing Department allowing for superior client satisfaction. Responsible for accurate and timely completion of all clients Allscripts Misys Tiger, Allscripts Pro PM database file builds, Practice Insight/e-Solutions file builds to include maintaining documentation to support all file builds and follow-up processes.  Responsible for daily file maintenance within Allscripts Misys Tiger, Allscripts Pro PM and Practice Insight/e-Solutions.  Responsible for ensuring daily that all claim submissions for each client is successfully received at the Clearinghouse and monitoring rejections/denials to ID trends and/or that resolution is being sought timely by the AR Department.   Responsible for balancing each database prior to month end close, daily/monthly closing of all databases and preparing month end reporting packages.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

  • Ensures that accurate daily, weekly, and monthly Insurance AR and Patient AR billing functions are performed as scheduled and reconciled and any submissions deficiencies are identified immediately (within 2 business days).
  • Demonstrates thorough understanding of claim submission function compliant with Federal and State regulations and RC Billing policy and procedures.
  • Ensures daily receipt and accurate balancing of clearinghouse EDI reports with the billing database claim submission file report.
  • Ensures timely daily resolution of Clearinghouse EDI edit report(s) and Payer edit report(s) by monitoring the Invalid reports per client in Practice Insight/e-Solutions.
  • Prepares and maintains the EDI Daily Claim Submission Reconciliation Batch Sheet ensuring all claims are received at the clearinghouse for each applicable client. If the Clearinghouse report doesn’t balance with the system billing reports management is immediately made aware via the Batch Sheet report and verbally.  The EDI Daily Claim Submission Reconciliation Batch Sheet and supporting clearinghouse and system reports are attached and submitted to management daily for review and sign off.  Batches are to be maintained on the RCB Shared Drive.
  • Ensures that all claims are submitted via electronic format for all payers accepting electronic submissions. 
  • Notifies Credentialing/Contracting Department and management of any clearinghouse enrollments (EDI & ERA) necessary to accomplish electronic submission and electronic remit advice for existing and new clients.
  • Prepares and maintains the Daily Patient Statement Log per client.
  •  Daily performs the Daily Close processes for each Allscripts Misys Tiger database and ensures strong communication with CBO Management team and the staff in the event a database daily close is not completed.
  • Completes month end close processes as assigned and recognizes this position requires overtime and no PTO is authorized during month end close schedule.
  • Reports any and all claim submission and/or file maintenance issues/concerns immediately to the CBO management, President and Director of Operations.
  • Notifies Credentialing/Contracting Department of any physician and/or payer credentialing issues for resolution.
  • Completes initial database build and maintains initial database file builds for all clients on the RCB Shared Drive and maintains on a go forward basis.
  • Completes initial setup in Practice Insight/e-Solutions for each client and physician and maintains going forward.
  • Ensures strong communication between CBO management team and Revenue Cycle IT and Credentialing Departments when appropriate and promptly responds to any and all high priority issues with immediate response and planned resolution.
  • Completes all fee schedule file builds within 2 business days of receipt and ensures fees are loaded accurately, standard fee schedules and payor contracted allowable fee schedules.  Any fee schedule requests with a client directive for an effective date must be completed prior to the effective date and activated on the accurate date.  Fee schedule file builds always take priority over general tickets submitted.
  • Completes all Tiger EDI Support tickets within Spiceworks accurately and timely ensuring compliance with standard set within the RCB P&P’s.
  • Ensures compliance with RC Billing Reimbursement Policies and Procedures to maximize efficiency.  Ensures compliance with appropriate industry regulations and State and Federal regulations.
  • Maintains working day to day knowledge of all practice management system(s) and Clearinghouse software.
  • Maintains working knowledge of applicable laws and regulations as they relate to assigned responsibilities.
  • Maintains confidentially of all information related to patients, medical staff, finances and cost effective health care delivery issues.
  • Strives to achieve and maintain company Days Sales Outstanding, Account Receivable Aging standards and monthly client collection goals.
  • Strives to achieve all CBO goals.
  • Additional duties as assigned.

EDUCATION AND/OR EXPERIENCE:

  • High school diploma or equivalent. 
  • Minimum five (5) years applicable medical billing experience.

QUALIFICATIONS:

  • Knowledge of organization policies and procedures.
  • Knowledge of health care administration principals.
  • Knowledge of business office procedures.
  • Knowledge of insurance agency operating procedures and practices.
  • Knowledge of electronic claim submission requirements to include required loop and segments.
  • Skill in exercising initiative, judgment, discretion and decision -making to achieve business unit objectives.  Skill in identifying and resolving problems. 
  • Ability to communicate effectively and professionally. 
  • Ability to establish and maintain effective professional working relationships with all employees and clients.   Knowledge of CPT-4, HCPCS and ICD-10 coding. 
  • Ability to communicate effectively orally and in writing.

CERTIFICATIONS / LICENSURES / CREDENTIALS: None

SUPERVISORY RESPONSIBILITIES:  None

PHYSICAL DEMANDS:

The physical demands described are representative of those that must be met by an employee to successfully perform the essential functions of this position.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.  This position requires full range of body motion including manual and finger dexterity and eye-hand coordination.  The position additionally requires standing/sitting for extensive periods of time.  Occasional lifting and carrying items weighing up to forty (40) pounds may be required.  Requires corrected vision and hearing to normal range.

WORK ENVIRONMENT:

The work environment characteristics described 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 functions. Work is performed in an office environment involving frequent interaction with staff, clients and the general public.

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