Job Description

Summary of Position/Objective

We are seeking a detail-oriented and proactive Medical Billing Specialist to manage and resolve denied insurance claims efficiently and accurately. The ideal candidate will have a strong understanding of medical billing, Medicaid coverage and insurance policies, and payer regulations. This role is crucial in ensuring prompt reimbursement and maintaining the financial health of the healthcare provider.

Essential Duties and Responsibilities

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The duties include, but are not limited to, the following:

• Funding Validation:
  • Regularly monitor Medicaid eligibility for member services and benefits.
  • Track authorization status to ensure timely and accurate support for members.
  • Coordinate maintenance of necessary funding sources for services and procedures.
• Denied Claims Management:
  • Review and analyze Explanation of Benefits (EOBs) and Electronic Remittance Advices (ERAs) to identify denial reasons.
  • Investigate and resolve denied claims through corrections, resubmissions, and appeals.
• Appeals and Follow-Up:
  • Draft and submit appeal letters with supporting documentation to insurance payers.
  • Monitor and track the status of denied claims and appeals to ensure timely resolution.
  • Communicate with insurance companies to clarify denial reasons and obtain resolution.
• Claim Review and Corrections:
  • Verify patient and insurance information for accuracy and completeness.
  • Identify and correct errors in coding, demographic information, and claim submission processes.
  • Collaborate with coders, providers, and other departments to resolve documentation and coding discrepancies.
• Compliance and Documentation:
  • Maintain accurate records of denial resolutions, appeals, and payer communications.
  • Ensure compliance with HIPAA and payer-specific regulations.
  • Update systems and logs to reflect claim status and outcomes.
• Prevention and Analysis:
  • Analyze denial trends to identify root causes and implement preventative measures.
  • Provide feedback and training to staff on common denial reasons and payer guidelines.
  • Stay updated on changes in payer policies and industry regulations.

Competencies/Qualifications/Education

Education:

• High school diploma or equivalent required. Associate's degree in healthcare administration, medical billing, or related field preferred.

Experience:

• Minimum of 2-3 years of experience in medical billing, claims processing, or denial management.

Skills:

• Strong analytical and problem-solving skills.

• Excellent written and verbal communication abilities.

• Proficiency in medical billing software, EHR systems, and Microsoft Office Suite.

• Detail-oriented with the ability to manage multiple tasks and meet deadlines.

Certifications:

• Certified Professional Biller (CPB), Certified Professional Coder (CPC), or equivalent credential preferred.

Key Competencies:

• Knowledge of insurance claim processing and denial resolution procedures.

• Ability to interpret and apply payer-specific guidelines.

• Strong organizational and time management skills.

• Collaborative team player with the ability to work independently.

Certificates/Licenses/Registration

The employee shall possess a valid driver’s license and must be eligible for the agency’s vehicle insurance and provide proof of private vehicle coverage.

Supervisory Responsibility

Position does not directly supervise employees.

Physical Demand

The physical demands described here are representative of those that must be met by an employee at all times to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

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