Home Health Billing Specialist

Job Description

Job Description

Job Summary

The Home Health Billing Specialist manages the medical billing and accounts receivable functions specific to home health services. This role is critical to the agency's financial health, requiring specialized knowledge of regulatory compliance, particularly Medicare's Prospective Payment System (or PDGM, the Patient-Driven Grouping Model), and state-specific Medicaid rules.

Essential Duties & Responsibilities

A. Claim Preparation and Submission

• Verify Patient Eligibility: Check patient insurance coverage, benefits, and authorization requirements for services (e.g., nursing, therapy, home health aide) prior to billing.

• Medical Coding: Apply appropriate ICD-10-CM (diagnosis) and HCPCS/CPT (procedure) codes based on clinical documentation and the plan of care (e.g., the OASIS and Form CMS-485).

• Claim Generation: Prepare and submit accurate claims electronically via clearinghouses or directly to government systems (like Medicare's DDE system) for all payers (Medicare, Medicaid, Managed Care, Commercial Insurance, and private pay).

• Ensure Compliance: Review all claims for adherence to federal, state, and specific payer regulations to prevent delays or denials.

B. Accounts Receivable (AR) Management and Collections

• Payment Posting: Accurately post payments, adjustments, and denials received from all payers and patients to the respective accounts in the billing software.

• Denial Management: Research and analyze denied or rejected claims to determine the cause; correct and resubmit or file formal appeals promptly and accurately.

• Follow-Up: Aggressively follow up on outstanding or aging accounts receivable via payer portals, phone calls, and written correspondence to secure maximum and timely reimbursement.

• Collections: Manage patient self-pay accounts, calculate patient responsibility, send statements, and coordinate payment plans as needed.

C. Documentation and Reporting

• Record Maintenance: Maintain organized and detailed records of all billing activity, payments, denials, and communications related to patient accounts.

• Reporting: Generate and analyze key financial reports, including Accounts Receivable aging reports, denial trend reports, and collection reports, and communicate findings to management.

• System Integrity: Utilize and maintain proficiency in the agency's Electronic Health Record (EHR) and billing software (e.g., HCHB, Kinnser/Wellsky, Axxess).

Qualifications and Skills

A. Required Education and Experience

• High School Diploma or equivalent; an Associate's degree in Medical Billing, Health Administration, or a related field is often preferred.

• Minimum of 2-3 years of proven experience in medical billing, with a strong focus on Home Health and/or Hospice.

• Certification as a Certified Professional Biller (CPB) or similar credential is a plus.

B. Key Skills

• Expert Knowledge of PDGM (Patient-Driven Grouping Model).

• In-depth knowledge of Medicare and Medicaid billing and payment cycles.

• Strong understanding of medical terminology, anatomy, and physiology.

• Exceptional Attention to Detail and organizational skills.

• Proficiency in electronic billing software and the Microsoft Office Suite (especially Excel).

• Excellent Communication and Customer Service skills for interacting with payers and patients.

• Demonstrated ability to maintain patient confidentiality and adhere to HIPAA compliance standards.

Sphinx Home Health was established in 2008 with the mission of delivering the patients the care they deserve. Owned and operated by healthcare professionals. Joint commission accredited with multiple deficiency free surveys. Awarded the national TOP HOME CARE ELITE recognition many years. Receiving referrals form all hospitals in southeast Michigan

Company Description

Sphinx Home Health was established in 2008 with the mission of delivering the patients the care they deserve. Owned and operated by healthcare professionals. Joint commission accredited with multiple deficiency free surveys. Awarded the national TOP HOME CARE ELITE recognition many years. Receiving referrals form all hospitals in southeast Michigan