Full time, 1st shift opening - Medicare Biller & Follow Up Representative


Job Summary:


  • The Medi-Cal Biller and Follow Up Representative is responsible for the management of patient accounts from the point of admission to reimbursement from the payor.
  • Works directly with patients, internal departments, external business partners (IPA’s, provider relations, government payors and insurance companies) and clinical departments for delivery of service to include but not limited to:
  • Obtains the maximum reimbursement for hospital services, effectively maintains a professional and ethical relationship with all clients, payors and staff.
  • Has expert knowledge of payor contracts, CPT/HCPCS and ICD-10 codes, medical policies, LCD’s and medical terminology.
  • Works efficiently to ensure accounts are worked thoroughly and within a timely manner.
  • Thrives within a team atmosphere, has strong customer service expertise, has a strong ability to multitask and has proficient computer skills.


Job Specific Essential Functions:


  • Serve as the account representative for Hoag in working with insurance companies and/or government payors for resolution of payments.
  • Completes daily assigned accounts on the collection work-list.
  • Obtains the maximum amount of reimbursement by evaluating claims at the contract rate with the use of the contract management tool for proper pricing (Examples: APC, DRG, APRDRG).
  • Reviews and initiates the initial appeal for underpayments observing all timely requirements to secure reimbursement due to Hoag.
  • Conducts an audit of accounts for billing and regulatory requirements.
  • Help identifies charge capture and missing charge.
  • Recommends denial edits to help mitigate denials issues.
  • Reviews and completes payor correspondence in a timely manner.
  • Escalates to the payor accounts that need to be appealed due to improper billing, coding and/or underpayments.  Reports new/unknown billing edits to direct supervisor for review and resolution.
  • Has a strong understanding of the Revenue Cycle processes, from Patient Access (authorizations & admissions) through Patient Financial Services (billing & collections), including procedures and policies.
  • Has thorough knowledge of managed care contracts, current payor rates, understanding of terms and conditions, as well as Federal and State requirements.
  • Interprets Explanation of Benefits (EOBs) and Electronic Admittance Advices (ERAs) to insure proper payment as well as assist and educate patients and colleagues with understanding of benefit plans.
  • Understanding of hospital billing form requirements (UB04) and familiar with the HCFA 1500 forms.
  • Knowledge of HMO, POS, PPO, EPO, IPA, Medicare Advantage, Covered California (Exchange), capitation, commercial and government payors (i.e. Medicare, Medi-cal)and how these payors process claims.
  • Demonstrates knowledge of and effectively uses patient accounting systems.
  • Performs other duties as assigned.


Education, Training and Experience Required:




  • High school diploma or equivalent with 2-3 years of hospital billing and/or collection experience.


Skills or Other Qualifications:


  • Analytical, critical thinking and sound decision making skills.
  • Basic skills in Microsoft Office (Word/Excel). Ability to communicate in a clear and professional manner.
  • Strong interpersonal skills.
  • Ability to problem solve, prioritize and follow-through completely with assigned tasks.
Hoag Hospital Hoag Memorial Hospital Presbyterian
Full time
Newport Beach, California 92657, US