Medical Biller

PLEASE NOTE - This position may require temporarily relocation to other TONHC Facilities: Sells Hospital, Santa Rosa Health Center, San Simon Health Center, and San Xavier Health Center.

Position Summary:

Under general supervision, the incumbent is responsible for examining, verifying, and maintaining data involved in processing medical care claims for alternate resources reimbursement and performing other third-party billing-related duties. The primary function of this position is to bill/process all medical care claims timely to ensure reimbursement from third-party payers.

Scope of Work:

The work involves the review of medical claims to ensure accuracy and completeness and obtain missing information. The incumbent performs various accounting, budget, or financial management support-related duties or assignments related to medical billing.

Essential Duties and Responsibilities:

• Responsible for received claims up until Third-Party Payer has paid the claim.
• Receives and examines alternate resource claims to ensure they are complete with appropriate supporting documents.
• Verifies accuracy of health claim number that claimed amounts are authorized and that the items of services billed are allowed by appropriate regulations, decisions, directives, and other controlling guides.
• Identifies errors, omissions, and duplications in documents and contacts the individual to resolve the problem before the claim is approved and submitted for reimbursement.
• Abstracts all necessary information by auditing the appropriate E&M and assigning the correct CPT/HCPCS code, which most accurately describes each medically documented procedure.
• Uses official coding conventions, techniques, rules established by the American Medical Association (AMA), American Dental Association (ADA) (CDT-2), and the Health Care Finance Administration (HCFA) for assigning codes.
• Search and abstract all CPT coding, operative and therapeutic, and all other pertinent data from the medical records to identify and document appropriate patient care.
• Conducts a thorough review of all abstraction and search of records using guidelines to select the most accurate and descriptive codes per CPT/HCPCS coding system.
• Ensures billing outpatient claims are within six (6) business days from the date of services.
• Ensures billing inpatient claims are within ten (10) days.
• Batches bills and prepares all invoices and listing patient's names for submission to Blue Cross/Blue Shield Fiscal Intermediary, Medicare, Medicaid, Private Insurance, and any alternate resources.
• Maintains a transmittal log on claims transmitted electronically and ensures follow-up when files are sent electronically of all alternate resource bills.
• Serve as a contact person relative to any questions or problems with claims processing and coding problems.
• Makes recommendations for changes in methods and procedures, information dissemination, and other processing matters to resolve recurring problems and expedite processing actions.
• Determines that claims are correctly processed and that the total agrees with the pre-determined control totals.
• Review reports and listings to ensure that they are in balance, proper format, sequence, and valid data.
• Maintains a timely filing system that includes third-party documents, remittance advice, and transmittal from third-party payers, which advise changes in coverage or billing procedures.
• Provides technical assistance with processing and maintaining CPT coding, abstraction of the complete chart (outpatient), and compliance enforcement of all regulatory requirements.
• Identifies inconsistencies or discrepancies in medical documentation by notifying the appropriate providers and all other departments within the facility for complete charge capture and abstraction.
• Consult with the attending physician, laboratory personnel, and all other necessary departments for compliance with all regulations and guidelines pertinent to the False Claims Act and Facilities Compliance program in preparation for itemized billing.
• Adds and edits insurers to the insurer file, completes claim formats and works closely with Patient Registration to maintain the insurer file.
• Responsible for maintenance and control of unbilled claims for an assigned section of patient rec