Under the direct supervision of the Revenue Cycle Manager, the Billing Specialist II is the journey level position in the Billing Specialist Series. The Billing Specialist II may be assigned to either the reimbursement unit or payment posting. Staff may be cross-trained in either area where necessary.

Reimbursement
Responsibilities include but are not limited to the following: quality assurance with respect to payer reimbursement. Proactively reviews payments against contracted. Analyzes complicated contractual arrangements as determined by contractual agreements entered by Palomar Health Medical Group. Audits remittance codes from EOB's and RAs to ensure appropriate payment according to contractual arrangements. Communicates individual corrections to patient account representatives. Contacts payers regarding fee schedule and reimbursement errors. Identifies and communicates trends and reports to management. Oversight of all patient and payer refunds including reviewing and approving all refund requests submitted by billing team prior to management review. Maintains refund-tracking log and applies adjustment to appropriate accounts within billing system. Identifies refund trends for policy adjustment and training opportunity. Maintains fee schedule and payer reimbursement information for billing team reference. Responsible for researching, reviewing, and adhering to federal, state and local regulatory collection guidelines, as well as payor specific billing/collection guidelines. Ensures patient specific negotiated rates are attached to patient accounts and noted for account representative awareness. Oversees implementation and management of contract management system. Proactively identifies trends and opportunities in payer reimbursement and prepares recommendations for contracting team and management. Reviews all complex refund requests. Serves as a resource and trainer for others.

Payment Poster
Completes timely, efficient, and appropriate payment posting and credit resolution activities as assigned following payor and internal procedures with minimal supervision. Ensures all payments reconcile to deposits.
Appropriately adds/edits coverage based on received remittance to avoid future claims/payment issues. Reviews account for proper insurance assignment at encounter level. Understand adjustment codes and when appropriate to bill secondary insurance or patient. Correctly apply money to patient accounts and move payments between accounts and COB as necessary account. Patient credits are properly distributed and/or refunded as appropriate.
Appropriately utilizes payor and third party portals to obtain remittance files and EOBs. Run credit card, and virtual payments. Pull and process virtual credit cards from Lockbox. Works to assist in continual electronic remittance enrollment. Promptly and accurately responds to billing inquiries from patients, payers, and internal customers.
Continuously identifies issues and trends affecting quality and timely reimbursement and proposes potential solutions. Exceeds quality and productivity standards. Evaluates payer down coding and communicates with coding. Create an excel ledger to reconcile to lockbox. Posts professional collection agency payments. Proactively reviews credit balance accounts for corrections for payment corrections. Provides necessary education to team members. Posts specialty cap payments applied at the patient encounter level. Reviews all complex payment reconciliations. Serves as a resource and trainer for others. Extensive knowledge of medical billing rules, such as coordination of benefits, modifiers, Medicare, and Medicaid and understanding of EOBs preferred. Become proficient in the use of billing software within 4 weeks and maintain proficiency. Strong math skills required. Ability to communicate with diverse personalities in a tactful, mature, and professional manner.

Maintains high productivity and quality with minimal supervision. Works in collaboration with internal and external customers. Customer service and satisfaction are a key standard for all communications. Work will be subject to compliance reviews and productivity standards. Yearly continuing education is required.

Ability to speak and read English at a level that is sufficient to satisfactorily perform the essential functions of the position. Knowledge of standard office equipment (i.e., calculator, fax, photocopier) and personal computer and computer software skills (i.e., MS Windows, Excel, Access, Word, PowerPoint, internet, e-mail). Windows computer skills including proficient use of keyboarding, use of mouse or keys for functions such as selecting items, use of drop-down menus, scroll bars, opening folders, copying and similar operations required upon employment or within the 1st two weeks of employment to perform the essential functions of the job. Performs other duties as assigned. Follows Palomar Health Medical Group rules, policies, procedures, applicable laws, and standards. Carries out the mission, vision, and quality commitment of Palomar Health Medical Group.

 

Job Requirements