HMO Billing and Collections Specialist

General Purpose

The HMO Billing and Collections Specialist is responsible for recording all revenue, electronic claim submissions, and timely collection from all HMO payer sources.

Essential Duties

1. Monitors HMO claims by reviewing all HMO admissions, verifying eligibility, reviewing case management software, and ensuring payer and claim form is set up in patient records.

2. Ensures all billing and collections are pursued in a timely and effective manner for assigned centers, including researching, adjustments and rebills as needed.

3. Identifies reconsiderations, appeal opportunities, and collaborates and coordinates with facility staff to fulfill audit requests,

4. Completes HMO Triple Check with assigned centers to ensure UB-04 claim forms are correct, and all revenue is accounted for and booked correctly. Ensures HMO billing is submitted by the 5th business day and verifies receipt of claims by the 7th business day.

5. Follows PACS collections policy for all HMO payers and reports in a timely manner. Documents all collection efforts in the patient billing record and healthcare software.

6. Partners with the Managed Care Department to maximize revenues.

7. Monitors and follows up on HMO claims by utilizing insurance platforms. Acts as an insurance provider portal expert.

8. Ensures revenue is properly booked and billed by utilizing exclusion worksheets.

9. Research denials and over/under payments for all HMO claims.

10. Maintains in-depth knowledge of all HMO contracts and contract changes. Provides education and communication to team members regarding HMO contracts.

11. Utilizes provider manuals, cheat sheets, managed care resources, and information sheets to ensure billing and collections are accurate and follow HMO contract requirements.

12. Monitors case management software for current authorizations, ongoing authorizations and communicate with center's leadership team when authorizations are outstanding.

13. Maintains constant communication with the centers Administrator, Business Office Manager (BOM), AR Resource.

16. Provides exemplary customer service and professional communication in all interactions with PACS team members, vendors, and outside representatives.

17. Develops and maintains a professional relationship with payer representatives to ensure timely collections.

18. Collaborates with Director of Accounts Receivable to champion department initiatives and special projects.

19. Performs other duties as assigned.

QUALIFICATIONS AND EXPERIENCE

Minimum of 3 years' experience in a healthcare or accounting environment with an emphasis on HMO contracts, billing, and collections. Knowledge of HMO contracts and Medicare/Medicaid regulations preferred. Ability to creatively solve problems, be a team player, be well organized and flexible. Experience in the development and training in accounting procedures and rules, and multi-site coverage an asset. Must be proficient with Microsoft Excel, accounting software, and experiencing EHR and billing systems/software.

EDUCATION

Associate’s degree in business, accounting or finance or equivalent knowledge and skills obtained through a combination of education, training, and experience.

Language Skills

Ability to read technical procedures.  

Ability to read and comprehend policy and procedure manuals.  

Ability to effectively present information and respond to questions from managers and employees.

Mathematical Skills

Ability to apply concepts such as fractions, percentages, ratios and proportions to practical situations.

Reasoning Ability

Ability to solve practical problems.  

Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Certificates, Licenses, Registrations

Knowledge and experience with PCC preferred.

Physical Demands  

The essential functions of this position require the following physical abilities: Prolong use of computer. Standing and /or walking very frequently.  Sitting occasionally.  Reaching with hands and arms frequently, pushing/pulling very frequently. Talking and /or hearing very frequently.  Tasting and /or smelling very frequently.  Lifting up to 50 pounds frequently. Climbing, balancing, stooping, kneeling, crouching or crawling occasionally.  Close, distance, color, peripheral, and depth perception in vision: ability to adjust focus.    

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.  The noise level in the work environment is usually low to moderate.

Additional Information

Note: Nothing in this job specification restricts management’s right to assign or reassign duties and responsibilities to this job at any time. Critical features of this job are described under various headings above. They may be subject to change at any time due to reasonable accommodation or other reasons.  The above statements are strictly intended to describe the general nature and level of the work being performed. They are not intended to be construed as a complete list of all responsibilities, duties, and skills required of employees in this position.

We are an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status, or any other legally protected status.