PT Medicare Representative
Patient Business Services - Modesto, CA

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Job Title: Medicare Representative Reports To: Medicare Supervisor

Department: Medicare Location: Patient Business Services

FLSA Status: Non-Exempt


The Medicare Representative is responsible for the follow-up on all Medicare insurance claims. The incumbent will resolve unpaid accounts in a timely and efficient manner for one or more geographical areas, while maintaining quality and productivity standards set for the Level 1 Medicare Representative.

Essential Duties and Responsibilities:
  • Review, modify as necessary, and re-bill rejected/denied claims in “queue” by assigning appropriate payor codes.
  • Process “queues” within appropriate timeframes, (e.g. claims status checks, appeals of denied claims).
  • Recode Medicare claims, assigning proper condition codes/ICD-9 codes/procedure codes into the Accounts Receivable Billing System and re-file claims as necessary.
  • Update appropriate modifiers, based on origin and destination of trip and change insurance claims as necessary.
  • Create narrative in the Accounts Receivable Billing System to document status of trip for use in claim appeal process.
  • Ensure that charges are billable to a particular government payor, based on the payor’s criteria, (e.g. Prospective Payment System (PPS), Diagnostic Related Group (DRG)).
  • Resolve payment issues with carriers, (e.g. denials, partial payments, etc).
  • Process daily claims reports, (e.g. “Collection Plan Audit”, “Unpaid Claims”, “CSR Queues”).
  • Process incoming correspondence, including signature letters, denials, Physician Certification Statements (PCS), prior authorizations and additional information necessary to release the claim.
  • Forward all credit card payments to Cash Posting when identified in Patient Care Report (PCR), correspondence and/or Computer Aided Dispatch (CAD) notes.
  • Determine the Level of Service to be billed, based on supporting documentation on the PCR and/or in the CAD notes, including but not limited to, designating Advanced Life Support (ALS), Basic Life Support (BLS), Wheelchair, or Specialty Care Transport (SCT)/Critical Care Transport (CCT).
  • Review clearinghouse transmission listings and in-house error logs, carrier acknowledgment reports make appropriate corrections.
  • Resolve incoming calls from carriers, providers and patients.
  • Process repetitive patient accounts according to payor and AMR Compliance guidelines.
  • Verify eligibility of benefits via Internet and/or telephone.
  • Process transports cancelled from the collection agency according to payor guidelines.
  • Submit adjustments or refund requests to the Cash Department when necessary.
  • Escalate the appeal process with payors as needed.
  • Gather requested information as required, (e.g. compliance audits, QA audits).
  • Adhere to all company policies and procedures.
  • Adhere to and comply with information systems security. Know and follow Information Systems security policies and procedures. Attend Information Systems security training, when offered. Report information systems security problems.

Non-Essential Duties and Responsibilities:
  • Work in a spirit of teamwork and cooperation.
  • Convey a sense of competence and commitment.
  • Use initiative to learn new skills, enhance personal knowledge and improve communications.
  • Demonstrate an ability to work well with team members.
  • Communicate a willingness to help others succeed.
  • Share workspace and resources as necessary.
  • Perform other duties as required.

Minimum Qualifications:


High School Diploma or GED required; Associates Degree or certificate of completion from a coding and billing school preferred.

Experience: Minimum one (1) year previous medical billing experience required, ambulance billing experience preferred.

Knowledge and Skills:
  • Medical transportation processes.
  • Terminology on a PCR, Hospital Face Sheet, and/or a CAD Sheet.
  • Process of signature and paperwork compliance.
  • Payor-specific requirements for one or more geographical areas and/or financial classes.
  • Distinctions between ALS/BLS/SCT/Gurney/Wheelchair/CCT levels of service.
  • ICD-9 coding/condition codes and procedure codes.
  • Government coverage guidelines, filing limits and necessary prior authorizations.
  • Medical terminology and insurance terminology.
  • Internal Compliance guidelines
  • Appeal levels and the redetermination process.
  • HIPAA requirements.
  • Proficient in the Accounts Receivable Billing System and Internet, (e.g. Internet mapping programs, eligibility websites, address search engines).
  • Basic understanding of Microsoft Word and Excel.
  • Communicate effectively, (both orally and in writing) in English.

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