Medical Policy Specialist jobs in Benton Harbor, MI

Commitment to Customer Service 

 Service encompasses all aspects of the Pokagon Band of Potawatomi Indian’s governmental operations.  Every employee shares the responsibility to provide exemplary customer service, dignity, and respect to all Tribal Citizens, the Tribal Council, and staff members.  To this end, all employees have an obligation to identify and report any service problems, issues, or concerns and through designated channels, initiate, recommend, and actively participate in solutions. 

 Position Summary:  Serve clients by completing healthcare claim requests for payment, reviewing the electronic health record, charge capture, superbills, and computer-generated reports, and other reporting tools to identify conditions treated and the services provided to each patient. Timely and accurate coding review of diagnoses, billable services and procedures performed by Providers, and supplies, utilizing the appropriate coding system including ICD-10, CPT and HCPCS or ADA codes. Prepare and submit electronic and paper claims to the appropriate payer and accounts receivable/denial management and follow-up.  

Essential Functions: 

• Examine registration data, insurance coverage, eligibility, and benefits, review the health record, computer generated reports, and other reporting tools to identify conditions treated and the services provided to each patient as well as reimbursement available for services. 
• Submit claims to payors, either electronically or on the appropriate claim form, and work front end edits in billing software as well as clearinghouse. 
• Work aged accounts and rejections, prioritize based on timely filing, look up payer eligibility using payer websites or contact payers to gather needed information for billing. Fix claim issues, update accounts and promptly re-bill.  
• Submit appeals and identify credit balances and forward repayment requests to supervisor. 
• Obtain and submit copies of dental/medical documentation as required or requested by third party payers. 
• Post payments received to computer business office software and other Pokagon Band record keeping systems. Prepare daily or weekly check posting deposit summary and submit to the Healthcare Revenue Cyle Manager or Staff Accountant. 
• Identify services and procedures provided but not adequately documented in the health record. Advise providers on requirements for documentation, complete dental/medical billing chart audits, review rejection code trends, and provide feedback on billing compliance and ways to maximize insurance revenue to the Healthcare Revenue Cycle Manager.   
• Prepare monthly reports including Aged Balance report and Payments, Charges and Credits report.  
• Review uncollectable account balances and denied dental/medical claims and make recommendations for bad debt, timely filing, and other write offs.  
• Work closely with insurance companies to ensure maximum reimbursement. 
• Routine management of accounts receivable. 
• Maintain technical knowledge, understand Tribal Health regulations, and keep current with changes in dental/medical coding requirements, and third-party payer reimbursement policies through continuing education, seminars, workshops, etc. 
• Maintain up to date knowledge of insurance regulations and requirements. 
• Assist patient registration with insurance verification questions and plan changes. 
• Act as a coding resource for dental/medical providers. 
• Collaborate with department managers and staff to provide updates and guidance on insurance policies and procedures. 
• Complete Prior authorizations/Pretreatment estimates as needed per insurance plan.  
• Complete monthly statements and manage patient accounts, send out collection notices as needed. 
• Initiate and manage insurance refunds within EDR/EMR. 
• Assist with policy creation.  
• Identify Areas of deficiency in registration records and provide education and training. 
• Maintain patient confidentiality and comply with all HIPPA regulations. 
• Review charges for diagnoses, modifiers, and all billable services performed or ordered by providers, including Physicians, Dentists, Chiropractors, Advanced Practitioners and Licensed Counselors, using the appropriate coding system including ICD-10-CM, CPT-4, and HCPCS or ADA codes. 

Non-Essential Functions: 

• Assist with Provider training in billing procedures and documentation requirements. 
• Perform other related functions as assigned.  

 Equipment: 

• Standard office equipment.   
• Systems used:  MS Office Applications, Internet, EMR or EDR software, Clearinghouse portals

 Position Requirements:   

• Knowledge of Medicare, Medicaid and commercial insurance plan billing regulations required. 
• Proficiency with MS Office Applications required. 
• Knowledge of HIPAA Privacy and Security Regulations required.  
• Strong sense of customer service and good communication skills, both oral and written required. 
• Ability to alleviate stress and anxiety and be supportive of persons and work tactfully, collaboratively, diplomatically and with highest level of confidentiality required. 

Medical Billing Specialist 

• Associates degree in position-related field, or certification in Medical billing and/or coding, or additional two (2) years medical billing experience required.  
• Minimum of three (3) years recent medical billing and/or coding experience required. 
• Electronic Health Record and medical billing software experience required; EPIC related experience preferred. 
• Knowledge of medical terminology and physician specialty coding and billing (e.g., family practice, behavioral health, podiatry, chiropractic) preferred.   

Indian Preference 

• Pokagon Band Preference Code applies. 

Physical Requirements:   

• Work is generally sedentary in nature and will frequently require sitting, however standing and walking will occasionally be necessary. 
• Frequently required to use hands and fingers to operate equipment.  
• Frequently required to talk and hear.  

Work environment: 

• General office environment. Lighting and temperature are adequate, and there are no hazardous or unpleasant conditions caused by noise, dust, etc.  

Competencies: 

• Job Knowledge 
• Interpersonal Skills 
• Dependability 
• Quality 
• Sense of Urgency  
• Integrity / Ethics 
• Attention to Detail