Billing and Utilization Management Specialist (77731)

Primary Responsibilities and Duties

• Ensures accurate claims processing and follow up.
  • Researches and resolves issues with claim rejections or other billing issues.
  • Performs electronic and manual posting of both insurance and persons served payments/adjustments to individual’s accounts.
  • Tracks outstanding claims, investigates issues, and coordinates corrections or appeals.
  • Prepares, reviews, and submits claims with accuracy and adherence to payer requirements.
  • Utilizes EHR optimally to audit claim status and troubleshoot issues.

• Provides professional and effective communication with internal and external customers as related to individual accounts.
  • Creates and issues invoices and payment reminders to persons served.
  • Processes credit memos and prepares account statements.
  • Monitors account details for non-payments and irregularities.
  • Communicates with payers, staff, and persons served to clarify documentation, eligibility, service, or claim needs.
• Authorization Management, Compliance, & Data Integrity.
  • Verifies medical necessity, service authorization, and payer requirements for ongoing or planned services. Submits medically necessary services (MNS) data electronically or manually to state-assigned contractors to secure service authorizations.
  • Imports authorization data efficiently, ensuring accurate processing within consumer payer records
  • Identifies and resolves MNS data discrepancies in collaboration with clinical staff to facilitate timely authorization requests.
• Obtains and documents approvals for services, ensuring timely submission of required clinical information.