Claims Billing Representative

JOB SUMMARY
Claims Billing Representative is responsible for the accurate and timely filing of claims to government,
commercial and contracted payers. The Claims Billing Representative works claim edits within a
contracted billing software vendor timely and accurately, ensuring correct filing of insurance claims.
The Claims Billing Representative must understand and comply with federal and state billing
regulation. The Claims Billing Representative must ensure the confidentiality and privacy of
information.
SCOPE AND COMPLEXITY
The work of this position is guided by defined policies, guidelines, and established practices and
precedents.
ESSENTIAL DUTIES AND RESPONSIBILITIES
1. Prepare and process insurance claims timely and accurately to government, commercial and
managed care payers.
2. Review and distribute corrected claims.
3. Enter appropriate account notes into the billing system to clarify actions taken to reconcile
claims.
4. Review daily edit reports from work queues and/or in external billing software and makes
necessary corrections or resolve claim edits to allow electronic submission.
5. Reviews and make appropriate actions to Medical Necessity issue, Local Coverage
Determination (LCD) edits, National Correct Coding Initiative (NCCI) edits, Modifier edits,
Payer specific edits, Medically Unlikely Edits (MUE), Procedure to Procedure (PTP) edits,
Add-on edits, Medicare Outpatient Code Editor (OCE).
6. Review error reports from electronic payers; identifies errors and makes appropriate
corrections to ensure accurate claim submission.
7. Verify eligibility for coverage via multiple payor websites.
8. Assure compliance with billing requirements for workers compensation and third-party
liability claim.
9. Maintains confidentiality of patient records at all times Observes HIPAA compliance.
10. Process re-bills as requested by collectors.
11. Perform as a team player.
12. Use logic, critical thinking and reasoning to identify the strengths and weaknesses of alternative
solutions to problems.
13. Understand the effects of new information for both current and future problem-solving and
decision-making.
14. High attention to detail
15. Attendance in accordance with company HR and department policies
16. Other tasks/functions that may be assigned by the company as per business requirement; these
may change from time to time to reflect the changing requirement of your position and our
business.
MARGINAL/ADDITIONAL FUNCTIONS
Contributes to a positive department image by exhibiting professionalism, adaptability, integrity,
teamwork and mutual respect with all staff members.
WORKING CONDITIONS & PHYSICAL REQUIRMENT
1. Pleasant work environment.
2. Job requires sitting and working at a computer for extended period of time; 8 hours minimum.
MINIMUM REQUIRED QUALIFICATIONS (SKILLS, KNOWLEDGE AND ABILITIES)
Education and/or Experience:
1. Bachelor of Science in Nursing graduate
2. At least one (1) year of experience in an insurance, finance, medical, hospital, or customer
service-related field.
3. Preferably with work experience in
a. Revenue Cycle (healthcare business, financial or insurance) experience.
b. Knowledge of medical and insurance terminology, ICD-10, CPT coding structures
c. Knowledge in billing forms (UB, CMS-1500)