Medicare and Medicare Advantage Biller

Position Summary

We are seeking a detail-oriented, experienced Medicare & Medicare Advantage Biller to join our Revenue Cycle team. This position is responsible for overseeing the full billing cycle for Medicare and Medicare Advantage claims, ensuring timely submission, resolution of claim issues, accurate payment posting, and regulatory compliance. The ideal candidate will have strong experience with Medicare Billing, claim resolution, all levels of Appeals, Pre and Post Payment Reviews, ABN (Advance Beneficiary Notice) and MSP (Medicare Secondary Payer) processes , and demonstrate proficiency in handling aging, denials, and reprocessing of behavioral health claims.

Work Environment & Remote Requirements

• remote position: candidates must have a reliable, high-speed internet connection and a secure, quiet workspace to perform job duties.

• Must reside in Ohio or be familiar with Ohio Medicaid and behavioral health billing requirements.

• Path Behavioral Healthcare will provide necessary equipment (laptop, phone, secure access to billing systems) upon onboarding.

• Must be able to attend virtual meetings and check in daily via Microsoft Teams, Zoom, or other company platforms.

• Must comply with all HIPAA regulations , including maintaining the confidentiality of patient information in a home-office setting.

Key Responsibilities

Claim Submission & Revenue Cycle Management

• Prepare and submit accurate claims to Medicare and Medicare Advantage plans for behavioral health services (MH & SUD) in a timely manner .

• Monitor the full revenue cycle including claim creation, submission, follow-up, payment posting, and account reconciliation.

• Ensure claims meet CMS requirements and payer-specific billing guidelines.

ABN & MSP Compliance

• Determine when ABNs (Advance Beneficiary Notices) are required and ensure they are issued and documented appropriately.

• Review and verify Medicare Secondary Payer (MSP) information for accuracy and update records accordingly.

• Coordinate with clinical and intake teams to validate insurance information and payer hierarchy.

Aging & Accounts Follow-Up

• Review aging reports weekly and prioritize accounts based on age and dollar value.

• Conduct proactive follow- ups with payers to resolve outstanding or unpaid claims.

• Escalate issues as needed to minimize revenue loss and improve AR turnover.

Claim Rejections & Denials

• Identify , analyze, and resolve rejected or denied claims.

• Research payer rejections and denials, and take corrective actions including adjustments, appeals, or resubmissions.

• Maintain detailed documentation of all denial activity and follow-up outcomes.

Payment Posting & Reconciliation

• Accurately post insurance and patient payments, including electronic remittance (ERA) and manual payments.

• Reconcile posted payments with bank deposits and remittance advices .

• Notify management of payment discrepancies, overpayments, or underpayments.

Appeals Management – All Levels

• Initiate and manage first-, second-, and third-level appeals for Medicare and Medicare Advantage denials, ensuring timely submission based on payer guidelines.

• Draft appeal letters , include supporting documentation (e.g., clinical records, ABNs, authorization letters), and maintain tracking logs.

• Submit reconsiderations, redeterminations, and ALJ (Administrative Law Judge) hearing requests when necessary.

• Monitor appeal outcomes, document responses, and take further action as required to secure reimbursement.

• Communicate with payers, including MACs (Medicare Administrative Contractors) and Advantage Plans, to clarify documentation needs and resolve disputes.

• Escalate unresolved or complex appeals to management with recommended action plans.

Pre- and Post-Payment Reviews

• Respond to Pre-Payment Review requests by gathering and submitting clinical documentation, provider records, and supporting billing information within payer-required timeframes .

• Track the status of pre-payment reviews and follow up with payers to ensure timely resolution and payment.

• Manage Post-Payment Reviews (e.g., RAC, CERT, ZPIC, or Medicare Advantage audits), including record retrieval, audit coordination, and documentation submission.

• Maintain audit logs, review findings, and assist in corrective actions or appeal submissions related to audit results.

• Work collaboratively with Compliance and Clinical teams to improve documentation practices and minimize risk of future reviews.

Communication & Collaboration

• Collaborate with front office, clinical staff, and other billing team members to resolve billing-related issues.

• Provide support in training and educating staff on Medicare billing requirements when necessary.

• Maintain confidentiality of patient and organization information according to HIPAA and company policies.

Qualifications

• High School Diploma or GED required, associate or bachelor's degree in healthcare administration or related field preferred.

• 3+ years of experience in medical billing, with at least 2 years focused on Medicare/Medicare Advantage.

• Strong understanding of CMS billing regulations, and behavioral health services.

• Proficient in medical billing software and EHR systems.

• Strong analytical, communication, and organization skills.

• Ability to work independently and manage time effectively in a remote or hybrid work environment.

• Knowledge of HIPAA and other healthcare compliance regulations.

• Ability to work independently and efficiently in a fully remote setting.

• Must have access to a secure and distraction-free home office environment.

Preferred Qualifications

• Experience working in a behavioral health setting or with Medicaid crossover claims is desirable.

• Familiarity with Ohio Medicaid and commercial payers is an advantage.

Benefits

• Remote position

• Competitive salary

• Health, dental, and vision insurance

• Paid time off (PTO) and holidays

• 401(k) retirement plan with employer match

• Professional development opportunities

• Supportive and inclusive work culture