Responsible for monitoring revenue cycle processes to identify potential areas of improvement in efficiency and profitability. Performs detailed level review of coding and documentation of services, ensuring that medical billing conforms to legal and procedural requirements. Processes third party payor claims, to include researching denial reasons, reviewing medical documentation, assigning accurate coding for diagnoses and procedures, and processing appropriate re-billing of outstanding claims. Provides revenue cycle training to providers and support staff as needed; serves as billing and coding expert resource for clinical and operations staff regarding billing and coding issues. Acts as liaison between operations and business office staff. 

DUTIES AND RESPONSIBILITIES:

1. Performs coding and auditing functions as part of the revenue cycle process. Researches pending claims placed in review or audit status due to payer denial, medical records request, invalid coding or other documentation issue. Reviews medical records for accurate code selection, highest level of specificity, documentation validation, and compliance with CPT and ICD-10 coding guidelines. 

2. Coordinates with department leaders to provide supplemental training for clinic support staff regarding coding compliance and third-party payer requirements on an as needed basis. Collaborates with billing and operations staff regarding revenue cycle continuous process improvement efforts, related both to value-based care and claims-based reimbursement. 

3. Periodically reviews payments from health plans to identify potential payment issues. Works closely with billing and credentialing staff to resolve payment issues with contracted health plans. Assists Director of Billing with EPM maintenance and updates of fee schedules, CPT/HCPCS/CDT (procedures) and ICD10 (diagnosis) codes, to include billing and pricing configuration.

4. Provides training for all levels of clinic support staff on revenue cycle processes and best practices. Serves as billing and coding expert resource for providers and clinic support staff. Acts as liaison between clinical and operations staff and business office department.

5. Serves as back-up for billing staff as needed. Completes special projects as needed (i.e. assist with the groundwork for electronic billing, completion of special reports, and problem resolution projects. 

6. Provides excellent internal/external customer service via telephone, email, or face-to-face contact to assist patients with their health care needs. Communicates with clients, support staff and third-party payors to address billing questions and concerns regarding charges, payments, adjustments, benefits, and possible refunds.

7. Records third party payments, disallowances, and adjustments in patient accounts via the patient account software. Identifies denials and recoupments; balances posted amounts to remittance reports, and ensures posting is completed by the pre-determined monthly closing date. 

8. Verifies third party benefit coverage to include co-pays, deductibles and co-insurance. 

9. Performs other related duties as assigned. 

JOB QUALIFICATIONS:

High School Diploma or equivalent

Bachelor’s degree highly preferred

Three years’ experience in billing and collecting of third-party health insurance

Significant expertise in billing and eligibility requirements for Medicare, Medicaid and private insurance

Two years’ experience training staff in a healthcare environment

Extensive knowledge of ICD-10-CM and CPT codes and medical terminology

Advanced knowledge of computerized billing systems

CPC, RHIT or equivalent EMR certification preferred

Auditor certification preferred 

Proven proficiency in Microsoft Word, Excel, Outlook 

Bilingual in English and Spanish preferred

Scheduled hours and/or work locations are subject to change

PHYSICAL ACTIVITIES AND REQUIREMENTS:

Finger Dexterity: Using fingers to make small movements such as typing or picking up small objects.

Talking: Frequently conveying detailed or important instructions or ideas accurately, clearly, or quickly.

Hearing: Able to hear average or normal conversations and receive ordinary information.

Repetitive Motions: Frequently and regularly using the wrists, hands, and fingers.

Visual: Average, ordinary, visual acuity necessary to prepare or inspect documents or other materials.

Physical: Limited physical effort required; May have to lift folders, files, papers, audio/video equipment, and other such items weighing up to approximately 25 lbs.