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.
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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