Collection Specialist w/ CPC

Position Description

The Collection Specialist w/ CPC (Certified Professional Coder) is responsible for maximizing revenue collection and denials for all Health Services FQHC Programs (Primary Care, Mental Health and Dental) and Specialty Clinics through review, submission and reprocessing of denied claims, coding training and claims creation with follow up.

Essential Job Functions

Essential Duties & Responsibilities including but not limited to: Coding Responsibilities: Provides review and/or coding of any coding related denied professional services for appropriate use of CPT, ICD-9, ICD-10, HCPCS, Modifier usage/linkage.

The following duties are mandatory requirements of the job:

Collection Specialist

• Initiate telephone calls to insurance companies to follow up on claims submitted that remain unpaid.   While maintaining confidentiality regarding patient information.
• Review patient information in eCW, EOB’s and insurance company portals to determine status of claims and investigate denied claims.
• Processes rejections and denials to determine if the claim needs to be re-billed or submitted for an appeal with the payer.  If correcting the claim, inform the billing specialist of the changes and/or the provider.

• Develop a comprehensive understanding of and adherence to all collection requirements for all insurance plans.  

• Maintain complete and accurate documentation of all activity performed.  Document work performed and action taken on open claims in eCW and/or via billing departments templates and spreadsheets.
• Maintain professionalism in all verbal and written communication with all insurance plans.  
• Reviews patient information in eCW to determine if an adjustment is valid and whether additional approval is required.

Certified Professional Coder

• Ensure staff is updated on policies and procedures as necessary to maintain compliance and reduce errors, providing training on an as needed basis. Use of ICD-10, CPT, and HCPCS coding systems and use of modifiers when necessary.
• Knowledge and/or familiarity with Primary Care, Dental, Mental Health and some specialty services such as GYN, Podiatry and Cardiology.

• Knowledge and/or familiarity with billing for a Federal Qualified Healthcare Center (FQHC), Mental Health Art. 28 and OMH Art. 31 programs.
• Takes initiative to query the physician for documentation or clarification to justify services.
• Resolve coding related claim issues in all phases: production, coding front end edits, and coding denial resolution with the Billing Director.
• Periodic review of CPT/Modifier/ICD-10 codes at least annually or as introduced or required from AMA or CMS.
• Reports coding and denial trends/issues to the team/providers for education within the coding department and/or physician education as needed.
• Perform retrospective and prospective coding and documentation chart reviews for professional fee services to ensure that the CPT/Modifier/ICD-10 codes selected support the services billed and adheres to local and federal coding guidelines.  Especially for new onboard providers first 90 days, then after on an as needed basis.
• Knowledge and/or familiarity with some of the billing rules and guidelines for Medicaid, Medicaid Managed Care, Medicare, Commercial and Third Party plans. 
• Ensure processes and claims submissions are compliant with all rules and regulations of the programs, state, federal and city requirements.
  
  

Other Responsibilities

The following duties are to be performed as assigned by the supervisor:

• Update claim demographics: insurance company, and patient information for submission of denied claims when necessary.
• Assist Billing Director with reports, assignments and special projects
• Send follow up letters to insurance companies and patients, as needed in a timely manner.

Education and Certification

List degrees, certificates, or number of years required as a minimum.  You may also include "preferred" or "desired" credentials or qualifications.

• High school diploma or higher required, or equivalent combination of degree and experience.
• 5-7 years of billing experience required.
• Certified Professional Coder, license with proof of passing the test required.
• Medical Billing and Coding certificate.

Special Skills and Knowledge

In addition to the above-listed job responsibilities and educational requirements, the ideal candidate for this position possesses most or all of the following:

• Must have a working knowledge in the usage of ICD-10/CPT4 codes.

• General knowledge of internet navigation and research, e-mail, fax transmission, and medical billing.

• Strong interpersonal skills and written and verbal communication skills.

• Familiarity with Microsoft applications including, but not limited to Word and Excel.