PFS Facility Medical Billing Specialist - 40 hrs/wk.

Blanchard-Valley-Health-System; Findlay (OH); On-site; USD 38,000 - 52,000; Full time

Job summary

Blanchard-Valley-Health-System seeks a Medical Claims Specialist to manage all aspects of claims, from pre-billing validation to follow-up, ensuring accurate, timely reimbursement. Collaboration with hospital departments helps ensure complete documentation and compliance.

The role emphasizes accurate data, payer communications, and adherence to HIPAA and regulatory requirements while promoting efficient revenue cycle processes.

Qualifications

• High school diploma or GED required.
• CPFSS certification within 12 months of hire.
• Familiarity with medical terminology and HIPAA requirements.
• Ability to manage multiple tasks and collaborate with others.
• Proficient in Microsoft Office, especially Excel.
• Strong time management and organizational skills.
• Valid driver's license and ability to operate a vehicle per BVHS policy.
• Knowledge to provide age-appropriate patient care and growth/development awareness.

Responsibilities

• Maintains HIPAA compliance and payer policy knowledge to enable compliant claims submission.
• Process daily electronic billing file to achieve clean first-time reimbursement.
• Corrects claims issues before submission by verifying demographics and eligibility.
• Educates staff when documentation is insufficient for billing.
• Prepares and submits manual claims for payers not accepting electronic claims.
• Monitors error reports to identify trends and process improvements.
• Monitors billing holds, escalates when needed, and reports trends to supervisor.
• Observes best-practice billing, follow-up, and customer service; reports compliance concerns.
• Identifies high-risk accounts and prioritizes follow-up with payors to secure timely payment.

Skills

HIPAA compliance

Excel

Time management

Organizational skills

Problem solving

Multitasking

Education

High school diploma or GED

CPFSS certification within 12 months

Tools

Microsoft Excel

Billing system

Job description

PURPOSE OF THIS POSITION

This position is responsible for all medical claims including pre-billing and follow up activities for delayed claims by ensuring, through various activities, that claims are clean and should be paid promptly by insurers without requiring further intervention. This staff member performs all pre-claim submission activities, including verifying existing information is accurate, determining when additional data is needed, and collecting necessary details to ensure claims are complete. Additionally, this individual follows departmental productivity and quality control measures that support the organization’s operational goals. This position promotes revenue integrity and accurate reimbursement for the organization by ensuring timely and accurate billing, timely payer follow-up activities and collection of accounts.

JOB DUTIES/RESPONSIBILITIES

• Duty 1: Maintains a thorough understanding and education of federal and state regulations and payer specific policies and requirements to promote compliant claims submission practices. Adheres to HIPAA related privacy, security and transaction & code set regulations in compliance with the federal guidelines. Accurately documents all account activity.
• Duty 2: Accurately and efficiently works daily electronic billing file through the organization’s billing system by resolving all necessary corrections with valid resolution to obtain a clean first-time reimbursement.
• Duty 3: Corrects all claims issues prior to submission which may be, but are not limited to, quality audits of patient demographic information and insurance eligibility, cross referencing with previous services, verifying payer authorizations, identifies and bills missing and late charges and corrects all necessary discrepancies. Submits required clinical documentation for submission with claims and collaborates with additional departments of the hospital to ensure claims are ready for billing and first-time payment.
• Duty 4: Educates staff in other departments when existing documentation is not sufficient for billing.
• Duty 5: Prepares and submits manual insurance claims to payers who do not accept electronic claims or who require special handling.
• Duty 6: Monitors and analyzes error reports to identify significant trends, process improvements or efficiencies and increase accuracy to achieve the overall goals of the department and organization.
• Duty 7: Monitors outstanding billing holds, escalates accounts as necessary, accurately works delayed claims and reports any trends, issues or findings to supervisor.
• Duty 8: Observes best practice billing, follow up and customer service activities and reports any suspected compliance issues to supervisor.
• Duty 9: Identifies high-risk accounts, prioritizes follow up efforts, efficiently contacts various insurance payors to determine reasons for outstanding claims and proactively communicates to facilitate timely payment of submitted claims.
• Duty 10: Investigates any over/underpayments and communicates with payers when necessary to rectify any pending or delayed claims.
• Duty 11: Proactively recognizes and rectifies any issues to prevent future insurance payor audits and communicates findings promptly to leadership.
• Duty 12: Regularly attends and actively participates in staff meetings, training and continuing education that aligns with recognized improvement opportunities, payer policies and procedures and ensures to maintain up to date certifications.
• Duty 13: The above duties reflect the general duties considered necessary to describe the principal functions of the job as identified and should not be considered a detailed description of all the work requirements that may be inherent to the position.

REQUIRED QUALIFICATIONS

• High school graduate or GED equivalent
• CPFSS certifications required within 12 months of hire (PRN status does not require certification)
• Familiarity with medical terminology and an understanding of HIPAA requirements
• Ability to perform project work which may require independent work or collaboration with others
• Proficient in Microsoft Office Programs, especially Excel
• Ability to manage multiple tasks and complex issues with excellent time management & organizational skills
• Demonstrated problem solving skills with excellent self-direction and creative solutions for operational efficiencies
• Adapts positively to changes in the working setting with ease
• A valid driver's license is required (if you do not have a valid Ohio driver’s license you must obtain one within 30 days of your residency in the state).You must also meet BVHS's company fleet policy and insurance company requirements, and any other requirements that may be required to operate a vehicle.
• Individual must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patient served on his/her assigned unit/department. The individual must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient status. Must be able to interpret the appropriate information needed to identify each patient’s requirements relative to their age-specific needs and to provide the care needed as described in the area’s policies and procedures

PREFERRED QUALIFICATIONS

• Associate’s degree, CPC certification or 2-3 years of experience in medical billing, coding or other revenue cycle functions preferred
• Conversant with various code sets (e.g., ICD-10, CPT, HCPCS, Modifiers, etc.)
• Familiarity with data elements on standard billing forms (e.g., CMS-1500)

PHYSICAL DEMANDS

This position requires a full range of body motion with intermittent activities in walking, lifting, bending, squatting, climbing, kneeling, and twisting. The associate will be required to sit for five hours a day. The individual must be able to lift ten to twenty pounds and reach work above the shoulders. This position requires corrected vision and hearing in the normal range. The individual must have excellent eye-hand coordination and verbal communication skills to perform daily tasks.