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Medical Biller, CMG Business Office

Full Time, 80 Hours Per Pay Period, Day Shift

Remote: Southeast U.S. (Eligible states: TN, KY, NC, GA, AL, VA, MS, AR, MO)

Covenant Medical Group is Covenant Health’s employed and managed medical practice organization, with more than 300 top Physicians and providers spanning the continuum of care in 20 cities throughout East Tennessee. Specialties include cardiology, cardiothoracic surgery, cardiovascular surgery, endocrinology, gastroenterology, general surgery, infectious disease, neurology, neurosurgery, obstetrics and gynecology, occupational medicine, orthopedic surgery, physical medicine and rehabilitation, primary care, pulmonology, reproductive medicine, rheumatology, sleep medicine and urology.

Position Summary:

This position participates in various functions including the review, correction, submission/resubmission, and/or appeal of rejected, denied, unpaid, or improperly paid insurance claims. This position is responsible for billing and follow-up functions for payors in all financial class categories. Serves as a resource for Medical Biller Is, seeking guidance from Supervisor when necessary. This positions also provides patient customer service and releases billing records to approved entities. This position responsible for the timely and accurate completion of assigned tasks to facilitate proper claim processing.

• Acts a resource for Medical Biller Is with resolving intermediate to complex account and claims issues.

• Provides guidance to other departmental roles (including Customer Service, Collections, Payment Posting) as it pertains to plan eligibility, claims processing details, and patient balance explanations as needed.

• Responsible for daily submission of primary, secondary, and tertiary claim billing via the clearinghouse, payor portals, and paper mailing. Reviews deficient claims (i.e. claim rejections) that are unable to be processed by the payor, makes corrections, and processes rebills as appropriate.

• Responsible for identifying financial and medical records necessary to support claim filing for all payor types for primary, secondary, and tertiary claims. Obtains and releases relevant documents as appropriate to facilitate timely and accurate claim processing.

• Demonstrates problem-solving and critical thinking skills in analyzing rejections and/or denials to determine root-cause and best course of action to resolve account issues. Able to identify rejection and denials trends and report to the appropriate contact for tracking and/or further investigation.

• Demonstrates knowledge and comprehension of State and Federal regulations, Medicare, TennCare, and other Third-Party Payor requirements, assuring departmental compliance.

• Possess an enhanced understanding of billing regulations, claim submission guidelines, payor policies, Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC), and payor-specific rejection and denial language; demonstrates the ability to interpret these relevant to determining proper steps needed to resolve accounts.

• Able to find, comprehend, and interpret payor processing and reimbursement policies relevant to assigned tasks. Maintains a working knowledge of medical terminology, CPT and HCPCS code sets, ICD-10 code set, and modifiers as it pertains to work assignment.

• Demonstrates the ability to extract pertinent information from payor correspondence and documents this in the practice management system. Interprets payor correspondence relevant to account resolutions and takes next steps as appropriate.

• Responsible for preparing and submitting payor reconsiderations and appeals. References relevant payor policies, claim submission and billing guidelines, and supporting documentation to obtain payor reimbursement in accordance with contracted rates.

• Analyses overpaid accounts and takes appropriate action to resolve overpayments including initiation of payor recoupment, refunding overpaid dollars to the appropriate party, and making appropriate transaction corrections in the practice management system.

• Demonstrates the ability to use registration system and payor websites to verify patient plan eligibility, coordination of benefits, and plan participation with CMG to ensure timely and accurate processing of accounts.

• Retrospectively reviews registration information obtained by CMG clinics impacting claim rejections and/or denials. In cases of incomplete or incorrect registration information, consults payor websites to obtain correct information. When necessary, contacts payors and/or patients via phone or mail to clarify deficient registration information.

• Consults and works collaboratively with leadership, coworkers, other departments, and other facility personnel to ensure accurate exchange of information and appropriate actions to resolve patient account/claims issues.

• Communicates effectively and professionally with patients/public, coworkers, physicians, facilities, agencies and/or their offices, and other facility personnel using verbal, nonverbal and written communication skills.

• Provides accurate explanation to patients with questions related to claims processing, plan benefits, and account balances via verbal and written communication. Act as a liaison between the patient, charge entry staff, and office staff in cases of patient dispute of charges billed. Demonstrates good judgment when handling financial discussions with patients, always maintaining a professional and confidential environment.

• Accurately processes practice management system transactions related to resolution of open accounts including but not limited to adjustments, transfer of payments, and refunds.

• Properly calculates and applies patient balance adjustments such as Self Pay Discounts and Good Faith Estimate Adjustments in accordance with departmental and organizational policies.

• Possess an enhanced understanding of the payment posting process and its impact relevant to claims follow up and account resolution.

• Recognizes situations which necessitate guidance and seeks from appropriate resources.

• Demonstrates promptness in reporting for and completing work, displaying the ability to manage time wisely to ensure timely and accurate completion of assignments.

• Adheres to established departmental policies and procedures.

• Follows policies, procedures, and safety standards. Completes required education assignments annually. Attends required meetings. Works toward achieving department goals and objectives. Participates in quality improvement initiatives as requested.

• Must achieve or exceed minimum expected work quality and quantity metrics as defined by department leadership. Skill set and competency to perform job requirements will be evaluated during initial 90-day training period.

• Performs all other duties as assigned or requested by leadership.

Minimum Education:          

Will accept any combination of formal education and/or prior work experience sufficient to demonstrate possession of the knowledge, skill and ability needed to perform the essential tasks of the job, typically such as would be equivalent to a high school diploma.

Minimum Experience:         

Three (3) years of experience in healthcare revenue cycle required (i.e., medical billing, insurance/precert verification, registration, Health Information Management (HIM), coding, claims management/insurance follow-up or appeals etc.). Will consider combination of formal education and experience. Professional certification may be considered as a substitute for no more than one year of experience. Knowledge of medical terminology and insurance payer rules, state and federal regulations is required. Must be able to problem solve, critically think, and work independently. Must be knowledgeable in use of PC, Windows, Excel, and Word. Expected to perform adequately and independently within three (3) to six (6) months on the job.

Licensure Requirement:      

None

Physical Requirements:

Type D

Job Relationship:

Interactions with patients and/or the public, insurance companies, physician office staff, operational staff, physicians, IT personnel and employees from other departments.

Equipment, Work Aids and Records:

Equipment utilization consists of telephone, PC, copier, printer, and fax. Records maintenance consists of scanned documents, medical records, correspondence with patients and payers, confirmation and contents of payer dispute submissions, and AR/credit reports.

Interpersonal Skills, Personal Traits, Abilities, and Interests:

Extensive contact with patients/customers requiring assistance with account resolution.  Discretion is required in non-routine situations.  Ability to work within a group setting and be a team player in a mature and positive manner.