Medical Billing Specialist

MEDICAL BILLING SPECIALIST

Department: Administration
Reports To: Revenue Cycle Director
Supervises: None
Status: Full-Time
FLSA Status: Non-Exempt

POSITION SUMMARY

The Medical Billing Specialist is responsible for accurate and timely billing, follow-up, and resolution of patient and insurance accounts for Rice Community Health. This position supports the hospital, Rural Health Clinics (RHCs), and other applicable healthcare services and is responsible for ensuring claims are submitted accurately, appropriately adjudicated, and followed through to payment or resolution.

The Medical Billing Specialist works closely with Revenue Cycle, Health Information Management, Registration, clinical departments, and external payers to identify and resolve billing issues that may delay or prevent reimbursement. The position requires a strong understanding of medical billing practices, payer requirements, hospital and RHC billing, and applicable federal and state regulations.

The successful candidate will demonstrate attention to detail, strong organizational and problem-solving skills, and the ability to manage multiple accounts and priorities while maintaining confidentiality and compliance with applicable laws and Rice Community Health policies.

QUALIFICATIONS

Education and/or Experience

• High school diploma or equivalent required.
• Associate's degree in medical billing, healthcare administration, accounting, or a related field preferred.
• Minimum of two years of medical billing, healthcare revenue cycle, or related experience preferred.
• Experience with hospital or facility billing preferred.
• Experience with Critical Access Hospital (CAH) and/or Rural Health Clinic (RHC) billing strongly preferred.
• Experience with CPSI/TruBridge and eClinicalWorks strongly preferred, particularly experience performing hospital and/or RHC billing within these systems.
• Experience working with electronic claims, clearinghouses, payer portals, and Electronic Health Record (EHR) systems preferred.
• Experience with UB-04 and CMS-1500 claims preferred.

GENERAL REQUIREMENTS / JOB DUTIES

To perform this job successfully, an individual must be able to perform each essential job duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and ability required.

Billing and Claims

• Review, prepare, and submit accurate and timely hospital, RHC, and other healthcare claims to third-party payers.
• Review claims for accuracy and completeness prior to submission and identify information that may result in denials or payment delays.
• Work clearinghouse edits, DDE errors, payer rejections, and other claim issues in a timely manner.
• Monitor claims from submission through adjudication and payment.
• Follow up on unpaid, underpaid, and delayed claims in accordance with established Revenue Cycle workflows.
• Research and resolve claim discrepancies involving eligibility, authorization, coding, medical necessity, billing requirements, and payer policies.
• Review accounts after insurance processing to ensure payments, adjustments, contractual allowances, and patient responsibility are accurately posted.
• Identify and resolve payment variances and potential underpayments.
• Process payer correspondence and take appropriate action to resolve outstanding issues.
• Maintain appropriate documentation of billing activity, follow-up, and account resolution within the applicable systems.
• Monitor accounts receivable and prioritize accounts based on aging, balance, payer requirements, and timely filing deadlines.
• Submit reconsiderations, corrected claims, appeals, and other payer requests as appropriate.
• Identify recurring billing issues and communicate trends or concerns to Revenue Cycle leadership.

Denials and Accounts Receivable

• Work assigned denial and accounts receivable reports to identify and resolve outstanding balances.
• Research the cause of denials and determine the appropriate corrective action.
• Submit corrected claims, reconsiderations, appeals, or supporting documentation as appropriate.
• Monitor accounts approaching timely filing or other payer deadlines.
• Identify patterns of denials or payment issues and communicate opportunities for process improvement.
• Assist with efforts to reduce accounts receivable aging and improve clean claim rates.

Payer and System Maintenance

• Maintain accurate payer information and billing requirements within applicable systems.
• Stay current on changes to Medicare, Medicaid, commercial payer, and other applicable billing requirements.
• Maintain working knowledge of CMS regulations, payer policies, and reimbursement requirements applicable to hospital and RHC services.
• Maintain proficiency in the EHR, clearinghouse, payer portals, and other systems necessary to perform assigned duties.
• Assist with identifying and communicating system or workflow issues that may affect billing or reimbursement.

Hospital and RHC Revenue Cycle Support

• Develop and maintain working knowledge of Critical Access Hospital and Rural Health Clinic billing practices and reimbursement methodologies.
• Apply applicable payer and billing requirements to hospital and RHC claims.
• Assist with billing issues related to hospital outpatient, inpatient, emergency department, clinic, and other facility-based services.
• Understand the distinction between professional and facility billing and appropriately route or resolve billing issues.
• Assist with identifying reimbursement issues that may be related to CAH, RHC, Medicare, Medicaid, or other payer-specific requirements.
• Work collaboratively with HIM, Registration, clinical departments, and other Revenue Cycle staff to resolve issues affecting reimbursement.

Reporting and Monitoring

• Review assigned accounts receivable and Revenue Cycle reports and take appropriate action.
• Monitor assigned work queues, aging reports, denials, rejected claims, and other billing reports.
• Assist with preparation and review of Revenue Cycle reports as requested.
• Track and communicate significant payer, billing, or reimbursement issues to Revenue Cycle leadership.
• Assist with identifying trends and opportunities to improve Revenue Cycle performance.

Compliance and Confidentiality

• Maintain compliance with applicable federal and state laws, Medicare and Medicaid requirements, payer regulations, and Rice Community Health policies and procedures.
• Maintain strict confidentiality of patient, financial, employee, and organizational information.
• Follow HIPAA and other applicable privacy and security requirements.
• Access patient information only as necessary to perform assigned job responsibilities.
• Maintain professional conduct and demonstrate sound judgment when handling confidential and sensitive information.

Other Duties

• Participate in department meetings, training, and continuing education as required.
• Assist other Revenue Cycle team members as needed to support department operations.
• Cross-train in applicable Revenue Cycle functions as assigned.
• Communicate effectively with patients, insurance representatives, providers, clinical staff, and other employees.
• Perform other duties as assigned.

REQUIRED KNOWLEDGE, SKILLS AND ABILITIES

• Knowledge of medical terminology, insurance terminology, and healthcare billing practices.
• Knowledge of hospital and/or RHC billing preferred.
• Knowledge of Medicare, Medicaid, and commercial insurance billing requirements.
• Understanding of medical claims, reimbursement, denials, and accounts receivable processes.
• Ability to accurately interpret payer correspondence and billing information.
• Strong attention to detail and accuracy.
• Strong organizational and time-management skills.
• Ability to prioritize work and meet established deadlines.
• Strong analytical and problem-solving skills.
• Ability to communicate effectively with patients, coworkers, providers, and insurance representatives.
• Ability to work independently while also functioning effectively as part of a team.
• Proficiency with Microsoft Office and standard computer applications.
• Ability to maintain confidentiality and exercise appropriate judgment when handling protected health information.

SECURITY / ACCESS

This position requires access to confidential patient, financial, and organizational information. The employee is expected to follow all Rice Community Health privacy, security, HIPAA, and information technology policies.

Access to patient and financial information must be limited to the minimum necessary to perform assigned job responsibilities.

EQUIPMENT USED

• Computer and related computer equipment
• Telephone
• Fax machine
• Copier/scanner
• Printer
• Other standard office equipment and software necessary to perform job duties

PATIENT AGE GROUPS SERVED

All age groups, as applicable to the services provided by Rice Community Health.

ESSENTIAL WORK ENVIRONMENT & PHYSICAL REQUIREMENTS

The work environment characteristics and physical requirements described below are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Primarily office-based work.
• Prolonged periods of sitting and working at a computer.
• Frequent use of a computer, keyboard, mouse, telephone, and other office equipment.
• Ability to communicate effectively in person, by telephone, and electronically.
• Ability to occasionally lift, carry, push, or pull office materials and equipment.
• Ability to maintain attention to detail and concentration for extended periods.
• May experience periods of increased workload and time-sensitive deadlines.
• Occasional movement throughout the facility may be required based on departmental needs.

ACKNOWLEDGMENT

This job description is intended to describe the general nature and level of work performed by employees in this position. It is not intended to be an exhaustive list of all responsibilities, duties, skills, or working conditions associated with the position. Duties and responsibilities may be modified, added, or removed as organizational needs change.