Specialist, Medicare

QHR Health, LLC dba Ovation Healthcare; United States; Remote; USD 50,000 - 74,000; Full time

Benefits offered by this job

Health benefits

HSA with employer contributions

Wellness platform

Paid time off & holidays

401(k) matching

Professional development

Company issued equipment

Job summary

Ovation Healthcare is seeking a Medicare Specialist to manage the billing and collection processes for Medicare patients, ensuring compliance with Medicare policies and regulations, and coordinating with Medicare representatives to resolve billing issues.

This 100% remote role offers comprehensive benefits, including health and wellness coverage, HSA, paid time off, 401(k) with match, and professional development opportunities, with Ovation Headquarters in Brentwood, TN.

Qualifications

• Knowledge of Medicare billing guidelines and regulations.
• Experience reviewing medical records and billing data.
• Ability to analyze claim data and resolve billing discrepancies.

Responsibilities

• Prepare and submit Medicare claims in compliance with guidelines.
• Identify unpaid/denied claims and follow up with due actions.
• Reconcile payments with remittance advice and address balances.
• Communicate with patients about coverage, questions, and options.
• Submit appeals for denied claims with supporting documentation.
• Monitor aging reports to prioritize follow-up and resolution.
• Ensure practices comply with Medicare regulations and HIPAA.
• Document all claims, payments, and follow-up activities.
• Collaborate with coding/finance to resolve claim edits.
• Prepare redetermination appeals to Medicare.

Skills

Medicare billing

Data analysis

Attention to detail

HIPAA compliance

Communication skills

Education

High school diploma or equivalent

Tools

DDE

CWF

EHR systems

Billing software

Job description

About the Job

Welcome to Ovation Healthcare! At Ovation Healthcare (formerly QHR Health), we have been making local healthcare better for more than 40 years. Our mission is to strengthen independent community healthcare. We provide independent hospitals and health systems with the support, guidance and tech-enabled shared services needed to remain strong and viable. With a strong sense of purpose and commitment to operating excellence, we help rural healthcare providers fulfill their missions. The Ovation Healthcare difference is the extraordinary combination of operations experience and consulting guidance that fulfills our mission of creating a sustainable future for healthcare organizations. Ovation Healthcare's vision is to be a dynamic, integrated professional services company delivering innovative and executable solutions through experience and thought leadership, while valuing trust, respect, and customer focused behavior. We're looking for talented, motivated professionals with a desire to help independent hospitals thrive. Working with Ovation Healthcare, you will have the opportunity to collaborate with highly skilled subject matter specialists and operations executives, in a collegial atmosphere of professionalism and teamwork. Ovation Healthcare's corporate headquarters is located in Brentwood, TN. For more information, visit www.ovationhc.com.

Summary

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, and 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.
• Utilizes DDE, CWF, and other tools to identify, track and follow up on unpaid or denied Medicare claims, identifying issues and working to resolve any billing discrepancies with Medicare or patients.
• 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.
• Prepares and submits 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.
• Identifies potential compliance risks and recommends corrective action.
• Maintains 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 may assist with preparation of quarterly Medicare credit balance report.
• Request offset to future payments in DDE.
• Work with internal departments, such as coding, finance, etc. to review diagnosis, CPT code, etc. to resolve claim edit issues.
• Prepare, submit, and follow up on redetermination appeals to Medicare.

Knowledge, Skills, and Abilities

• 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.

Work Experience, Education, and Certifications

• Experience utilizing Payer portals, DDE and client systems 3-5 years of hospital Business Office billing and follow-up experience as a Medicare representative.
• Medical Terminology, ICD-10, CPT and DRG knowledge a preferred, knowledge of third-party Insurance payer guidelines.
• High school diploma or equivalent.

Working Conditions

Work from home and remote location with a stable internet connection, a quiet and dedicated workspace free of distractions, and access to necessary office equipment. The ability to have daily communication with team members, management, and clients through email, phone calls, video meetings and other collaborative tools. Primarily requires sitting at a desk for extended period. Proper lighting and ergonomics shole be maintained to reduce eye strain.

100% Remote Benefits

The base compensation range for this position is: $49,603.71 - $74,405.56 Compensation ranges could be hourly or salary depending upon the exempt status of the posted position.

Compensation is only part of Ovation's total compensation package.

• Comprehensive health and wellness benefits such as medical, dental, vision, life insurance, short and long-term disability coverage
• HSA with employer contributions, flexible spending accounts for health care, and dependent care accounts
• Wellness platform with premium incentives
• Employee assistance support and additional voluntary supplemental plans including accident, critical illness, hospital indemnity, and child disability insurance
• Robust and flexible paid time off offerings and company paid holidays
• 401(k) plan with discretionary employer match opportunities
• Professional development opportunities
• Company issued equipment

Headquartered in Brentwood, Tenn., Ovation Healthcare partners with 375+ hospitals and health systems across 47 states. For 45+ years, Ovation Healthcare has supported hospitals and health systems through a portfolio of shared services - Leadership Advisory, Spend Management, Revenue Cycle Management, and Technology Services- designed to provide scale and efficiency to hospital business operations.