Specialist, Medicare

Duties and Responsibilities:

• Prepare and submit accurate Medicare claims for patient services, ensuring compliance with Medicare guidelines and regulations. Utilizes DDE, CWF, and other tools to identify, track and follow up on unpaid or denied Medicare claims, identifying issues and working to resolve any billing discrepancies with Medicare or patients.

• Review patient accounts and reconcile payments with Medicare remittance advice, ensuring all payments are posted correctly and outstanding balances are addressed. Communicate with patients regarding their Medicare coverage, billing questions, payment options, and any unpaid balances.

• Investigate and resolve issues related to denied or underpaid Medicare claims, working with Medicare representatives and internal departments to ensure accurate reimbursement. Prepares and submits appeals for denied claims, including supporting documentation.

• Monitor and analyze aging reports to prioritize follow-up actions for overdue Medicare accounts, ensuring timely resolution. Ensure all billing and collection practices are compliant with Medicare regulations, HIPAA, and company policies.  Identifies potential compliance risks and recommends corrective action. Maintains accurate records of all Medicare claims, payments, communications, and follow-up activities, ensuring proper documentation in the patient account system.

• Identify and resolve Medicare credit balances and may assist with preparation of quarterly Medicare credit balance report.  Request offset to future payments in DDE.

• Work with internal departments, such as coding, finance, etc. to review diagnosis, CPT code, etc. to resolve claim edit issues.

• Prepare, submit, and follow up on redetermination appeals to Medicare

Knowledge, Skills, and Abilities:

• Ability to analyze complex data, identify patterns, and draw accurate conclusions. 

• High level of accuracy in reviewing medical records and billing data.

• Ability to analyze claim data, identify billing errors, and troubleshoot complex claim issues. 

• In-depth knowledge of Medicare billing codes, guidelines, and regulations. Familiarity with electronic health record (EHR) systems, billing software, and remittance advice processing and DDE. Strong communication skills, with the ability to explain Medicare billing details and resolve patient concerns effectively.

• Ability to handle sensitive information and maintain confidentiality in accordance with HIPAA regulations. Detail-oriented with strong organizational skills and the ability to manage multiple accounts simultaneously. Problem-solving abilities, particularly with regard to billing discrepancies and denied claims.