Professional Billing Representative (PRN | As Needed)
Children's National Hospital
Summary
The Professional Billing Specialist will be responsible to ensure physician claims are complete, accurate and billed within the expected time frame according to internal billing policy, Federal and State regulations and Managed Care contract guidelines. Will be well-versed in HIPAA standards, NCCI coding and billing regulations for professional service claims to include hospital, specialty and primary care based services. Will develop detailed understanding of assigned managed care contractor and payor requirements. Will track and report billing trends with assigned carriers.
Job description
About the Role
The Professional Billing Specialist will be responsible to ensure physician claims are complete, accurate and billed within the expected time frame according to internal billing policy, Federal and State regulations and Managed Care contract guidelines. Will be well-versed in HIPAA standards, NCCI coding and billing regulations for professional service claims to include hospital, specialty and primary care based services. Will develop detailed understanding of assigned managed care contractor and payor requirements. Will track and report billing trends with assigned carriers.
Functional Accountabilities
Queue Management
- Monitor claims outstanding and report daily using various sorts to manage daily claim volumes and timelines according to policy.
- Monitor claim errors by Form and report trends, new incidents, duplications, incorrect payer mix and unusual volumes.
Productivity
- Research and take action on all failed claims to bill or pend on hold for additional information by the end of the import day.
- Follow-up and resolve claims in Held status daily.
- Bill secondary claims no less than twice a week. Maintain age less than 5 days from import.
- Process 150 to 200 claims addressed per day contingent on assignment.
Quality
- Coordinate supporting documents to ensure validity for services billed.
- Audit claim details for standard claim data prior to submission to ensure accuracy and complete edit satisfaction.
- Follow written procedure, payer policy, guidelines and edit instruction completely.
- Stay abreast of payer updates on at least a quarterly basis and share changes with Leadership and Team.
Claim Corrections and Billing
- Research coding errors using CPT and ICD guidelines, Craneware and NCCI tools, Medical Records and Account Systems. Following procedure pursue authorization for code corrections.
- Apply data corrections to claim and/or host systems performing transaction updates/same claim or charge corrections/new claim as outlined in procedures.
- Apply claim notes to provide detailed explanation to downstream users when claims are pending corrections (Held claim) or not billed (Archive/Del). Document the: (1) Problem, (2) Research, (3) Findings, (4) Action Taken, (5) FU plan.
- Coordinate submission of supporting documentation, e.g., treatment plans, operative reports, EOB.
Requirements
- High School Diploma or GED (Required)
- Associate's Degree/Healthcare Billing Vocational Training (Preferred)
- 2 years Professional service billing or related education in a physician clinic practice or billing office (Required)
- Analytical problem solver, detail oriented, efficient, and productivity driven
- Ability to process large volumes on a daily basis
- Well-versed in HIPAA standards, NCCI coding and billing regulations for professional service claims
- Knowledge of CPT and ICD guidelines
- Experience with Craneware and NCCI tools, Medical Records and Account Systems
Benefits
- Nationally Recognized Excellence
- Leading Pediatric Care
- Innovation & Research
- Mission-Driven Culture
Company overview
Children's National Hospital is a premier pediatric healthcare institution located in Washington, D.C., recognized as one of the top children's hospitals in the United States. Founded in 1870, it serves as the region's primary pediatric academic medical center, providing comprehensive care across all pediatric specialties. The hospital operates a 323-bed facility and offers advanced medical services including neonatal intensive care, pediatric surgery, oncology, cardiology, and neurology. As an academic medical center affiliated with the George Washington University School of Medicine and Health Sciences, Children's National is deeply involved in pediatric research, medical education, and clinical innovation. The institution is particularly renowned for its Sheikh Zayed Institute for Pediatric Surgical Innovation and its leadership in pediatric genomics and precision medicine. Children's National consistently ranks among the top pediatric hospitals nationally, with specialties in cancer, cardiology, neurology, and neonatology receiving particular recognition for excellence in patient care and outcomes.