SG Homecare

Billing Specialist

• Collaborate with global and domestic cross-functional teams to resolve patient questions, concerns, and issues related to Medicare coverage, claims, denials, and patient responsibility
• Handle high-volume inbound and outbound calls related to Medicare billing statements, coverage, payment plans, and coordination of benefits (COB)
• Accurately document all patient interactions, including inquiries, complaints, and resolutions, ensuring compliance with Medicare and internal documentation standards
• Interpret EOBs and explain Medicare patient responsibility, coverage limitations, and claim outcomes
• Verify insurance eligibility, benefits, and coverage through payer portals, with a focus on Medicare qualification and active coverage
• Review and recalculate invoices as needed to ensure alignment with Medicare billing rules and reimbursement guidelines
• Manage and resolve denials and appeals, ensuring proper documentation and adherence to Medicare requirements for medical necessity and claims processing including Medicare audits
• Request and validate clinical documentation, prescriptions, and supporting records required to meet Medicare medical necessity standards
• Coordinate with internal teams to ensure claims are clean, accurate, and ready for submission or resubmission
• Respond to patient communications across multiple channels, including phone, email, portal, and fax
• Route complex issues to appropriate teams while maintaining ownership of resolution
• Ensure adherence to HIPAA, confidentiality, and Medicare compliance requirements at all times
• Follow up on open tasks, worklists, and outstanding issues in a timely manner
• Support equipment recovery processes when treatment ends or Medicare benefits terminate
• Maintain knowledge of Medicare billing, reimbursement guidelines, and DMEPOS requirements

Medicare Specialist – Medicare Billing

Compliance

• Administer the Medicare compliance program, ensuring adherence to CMS regulations, Medicare guidelines, and DMEPOS standards
• Audit Medicare-related operational processes, including intake documentation, qualification, re-certification, and billing readiness
• Establish and monitor internal controls and auditing systems to identify compliance risks and operational gaps
• Serve as the primary compliance liaison across Intake, RCM, Customer Care, and Operations to improve Medicare workflows and resolve compliance-related issues.
• Conduct routine audits of patient documentation, billing readiness, and reimbursement processes to ensure regulatory compliance
• Interpret new and revised Medicare regulations and implement process updates to maintain compliance
• Develop and maintain compliance policies, procedures, and documentation standards
• Lead training initiatives and provide ongoing guidance to staff on Medicare documentation requirements, eligibility criteria, and billing standards
• Provide guidance related to audits, denials, and compliance concerns
• Prepare and present compliance reports, audit findings, and risk assessments to leadership
• Identify opportunities for operational improvement and support strategic initiatives related to Medicare growth and compliance scalability
• Provide guidance, onboarding support, and subject matter expertise to new team members as the department expands
• Perform other duties as assigned

Medicare Compliance Program Lead

Supervisor

• Supervise, coach, and develop Medicare Specialists and related support staff
• Conduct regular one-on-one meetings, performance evaluations, and productivity reviews
• Monitor staffing levels and distribute workloads to ensure timely and efficient order processing
• Create and implement training plans focused on Medicare regulations and operational best practices
• Oversee the review and processing of Medicare orders to ensure accuracy
• Ensure all required documentation is obtained prior to order fulfillment
• Review and resolve complex Medicare eligibility and documentation issues
• Monitor order queues and workflow backlogs to ensure service level expectations
• Maintain compliance with Medicare regulations and company policies
• Conduct quality audits of completed orders and team workflows
• Analyze trends related to denials and recommend corrective actions
• Collaborate with cross-functional teams to support efficient order processing and reimbursement success

Medicare Specialist – Medicare Billing

Medicare Compliance Program Lead

Medicare Specialist – Supervisor