Role Description The Medicare Specialist is responsible for managing the billing and collection processes for Medicare patients, ensuring compliance with Medicare policies and regulations, and following up on unpaid Medicare claims. This role involves:

• Processing Medicare claims
• Managing accounts receivable
• Addressing patient inquiries
• Working closely with Medicare representatives to resolve billing issues

Duties and Responsibilities

• Prepare and submit accurate Medicare claims for patient services, ensuring compliance with Medicare guidelines and regulations.
• Utilize DDE, CWF, and other tools to identify, track, and follow up on unpaid or denied Medicare claims, identifying issues and resolving billing discrepancies.
• Review patient accounts and reconcile payments with Medicare remittance advice, ensuring all payments are posted correctly and outstanding balances are addressed.
• Communicate with patients regarding their Medicare coverage, billing questions, payment options, and any unpaid balances.
• Investigate and resolve issues related to denied or underpaid Medicare claims, working with Medicare representatives and internal departments to ensure accurate reimbursement.
• Prepare and submit appeals for denied claims, including supporting documentation.
• Monitor and analyze aging reports to prioritize follow-up actions for overdue Medicare accounts, ensuring timely resolution.
• Ensure all billing and collection practices are compliant with Medicare regulations, HIPAA, and company policies.
• Identify potential compliance risks and recommend corrective action.
• Maintain accurate records of all Medicare claims, payments, communications, and follow-up activities, ensuring proper documentation in the patient account system.
• Identify and resolve Medicare credit balances and assist with preparation of quarterly Medicare credit balance report.
• Request offset to future payments in DDE.
• Work with internal departments, such as coding and finance, to review diagnosis, CPT code, etc., to resolve claim edit issues.
• Prepare, submit, and follow up on redetermination appeals to Medicare.

Qualifications

• Ability to analyze complex data, identify patterns, and draw accurate conclusions.
• High level of accuracy in reviewing medical records and billing data.
• Ability to analyze claim data, identify billing errors, and troubleshoot complex claim issues.
• In-depth knowledge of Medicare billing codes, guidelines, and regulations.
• Familiarity with electronic health record (EHR) systems, billing software, and remittance advice processing and DDE.
• Strong communication skills, with the ability to explain Medicare billing details and resolve patient concerns effectively.
• Ability to handle sensitive information and maintain confidentiality in accordance with HIPAA regulations.
• Detail-oriented with strong organizational skills and the ability to manage multiple accounts simultaneously.
• Problem-solving abilities, particularly with regard to billing discrepancies and denied claims.