Job Details

Summary
Performs a variety of complex billing and accounting functions . Review and process rejected claims, verify and work adjudicated claims, resolve and resubmit claims compliant with reimbursement eligibility. Ensure payments and denials are made in accordance with payer contracts and company procedures. Review of invoice information, maintain third-party billing records, and resolve variety of claims and contract issues.

Essential Duties and Responsibilities (Billing Processor I, II and CPC):

• Verifies member coverage, benefits and services allowed for Medicare, Commercial and AHCCCS payors.
• Confirms health insurance coverage for coordination of benefits to process claims
• Works with payors to request and resolve Prior Authorizations discrepancies.
• Resolves rejected and denied billing errors.
• Applies provider contract provisions to determine if claim is payable or denied.
• Determines if denied claims related to rendering provider, service location, coordination of benefits, refunds or adjustments.
• Reviews medical and behavioral claims, post payment or denial codes within established department guidelines and standards
• Maintain records, files, and documentation as appropriate
• Maintains billing, explanation of benefits, and Receipts filing system and records retention.
• Runs denials and cash receipts reports.
• Posts receipts and Explanation of Benefits (EOB) via manual posting.
• Routinely monitors and ensures eligibility segments are documented correctly in NextGen.
• Meet department production and quality standards
• Performs other related duties in accordance with agency growth and changes.

• Reviews and processes inbound 835 electronic response files (ERAs) for the assigned Medicaid payer.
• Reviews and resolves claim discrepancies and errors prior to posting the assigned Medicaid ERA.
• Responsible to communicate and resolve any posting errors with NextGen directly.
• Assigns denied and rejected billing claims to their Medicaid team members.
• Prepares and reports payor payment trends for the assigned Medicaid payer.
• Point of contact for communicating directly with the Medicaid provider representative.
• Point person to communicate and resolve denials and rejections for the assigned Medicaid payer.
• Reconciles Medicaid payer monthly payments to EFTs and communicates discrepancies to the supervisor.
• Assists billing team members with denied and pended billing errors.
• Assists with training specific to the assigned Medicaid payer.

• Answer calls and emails related to coding.
• Review denial notes to determine correctness in diagnosis, modifier & CPT code
• Assist providers in selecting correct CPT codes
• Assist Data Validation Audits

• 3 years billing & claims processing experience

• A minimum of 5 years billing & claims experience AND;
• A minimum of 1 year processing claims as assigned to the primary Medicaid ERA funder

• Active AAPC Certification

• Certified Coder, preferred

• Valid Arizona Drivers license, proof of current insurance and willingness to use personal vehicle.
• Clean Motor Vehicle Record - no more than 2 moving violations or a license suspension in past 3 years.

• Bilingual a plus.
• Ability to interact effectively with other service providers.
• Intermediate to advanced computer skills using MS Office products, Word, Excel, Access, etc., importing/exporting data to/from applications.
• Ability to communicate effectively both orally and in writing