Specialist, Medicare

QHR Health; United States; Remote; USD 65,000 - 85,000; Full time

Job summary

Ovation Healthcare, formerly QHR Health, seeks a Medicare Specialist to manage billing and collections for Medicare patients from a remote location in the United States. Responsibilities include processing claims, resolving denials, and coordinating with Medicare representatives to ensure compliant reimbursement.

You will analyze complex billing data, maintain HIPAA-compliant records, and support appeals with accurate documentation across departments.

Qualifications

• 3–5 years of hospital business office billing and Medicare follow-up experience.
• In-depth knowledge of Medicare billing codes, guidelines, and regulations.
• Familiarity with EHR systems, billing software, and remittance advice processing.

Responsibilities

• Prepare and submit accurate Medicare claims, ensuring compliance with guidelines.
• Review accounts and reconcile payments with remittance advice; address patient questions.
• Investigate denied/underpaid claims and submit appeals with supporting docs.
• Monitor aging reports and prioritize overdue follow-up actions.
• Ensure billing practices comply with Medicare, HIPAA, and company policies.
• Maintain thorough records of claims, payments, and communications.

Skills

Medicare billing

DDE/CWF

EHR systems

HIPAA compliance

Communication

Analytical skills

Detail-oriented

CPT/ICD knowledge

Education

High school diploma or equivalent

Tools

DDE

CWF

Job description

About the Job

Job Description

Welcome to Ovation Healthcare! At Ovation Healthcare (formerly QHR Health), we've 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 equi