Medical Billing and Coding Specialist

Summary

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Responsible for submitting all Primary, Secondary and Tertiary Claims (HCFA 1500 or UB-04) as appropriate.
• Participate in ongoing performance improvement activities to evaluate compliance with all coding guidelines.
• Performs all functions necessary in the EPIC, and EDI product to ensure timely claim submission and reimbursement of all Third Party Claims.
• Reviews patients’ medical records and assigns appropriate code(s) using the ICD- and CPT system. Records all surgical and designated diagnostic procedures and assigns appropriate procedure code. Requests for information from physicians and/or other clinical staff when not recorded on discharge or if information is incomplete.
• Compiles and/or post charges accurately, timely, and in compliance with federal and state insurance guidelines.
• Ensure that all required payor information and proper documentation are provided.
• Reviews claim transmission reports to validate the status of claims i.e. claim transmitted or failed.
• Corrects failed claims and provides information as appropriate to IS department to ensure claims process properly.
• Works with Payors and/or EDI product on claims not received in submitted batches. Reviews denied claims and resubmits claims as appropriate.
• Provides cashiering and associated duties.
• Analyzes and works accounts receivable on a regular basis, sends appeals, and does claim reviews daily.
• Interacts with physicians, completing applications, and practicing set-up.
• Provides accurate and timely billing services for all patient types to third party payors, Medicare, Medicaid, Veterans Insurance, Worker’s Compensation, Automobile Insurance, Liability Insurance and Self Pays.
• Updates demographic and insurance information as necessary.
• Forwards code updates to system support immediately upon implementation.
• Maintains current knowledge of ICD- and CPT coding guidelines.
• Works with clinic and business staff to ensure all claims are submitted correctly and assists in the formation of appeals to ensure correct reimbursement for services provided.
• Works with Physicians and staff on updating information by specialty. Participates in educating and training physicians and staff in coding.
• Responsible to understand Medicare compliance regulations.
• Sends delinquent accounts to collection agencies.
• Processes insurance payments, with special focus on Medicaid and Medicare, to patient accounts in computerized systems.
• Creates and mails insurance claims and patient statements.
• Rebills insurance companies or other third parties to secure payment for patients.
• Verifies all entries made by Medical Office Assistants and makes corrections if necessary.
• Trains appropriate personnel on computerized billing systems on an as needed basis.
• Participate in CPI program. Maintains compliance, is knowledgeable, and utilizes the guidelines of all state and federal laws and regulations as they pertain to the position including, but not limited to; Health Insurance Portability Accountability Act (HIPAA), Scope of Practice, Accreditation Standards, Occupational Safety and Health Administration (OSHA), Bureau of Primary Health Care/ Health Resources and Services Administration (BPHC/HRSA), National Committee for Quality Assurance/Patient Centered Medical Home (NCQA-PCMH), Centers for Medicare and Medicaid Services (CMS), Clinical Laboratory Improvement Amendment (CLIA), Joint Commission on Accreditation of healthcare Organizations (JCAHO), and other HRSA related regulatory functions and/or agencies that Family Circle of Care participates in.

Patient Centered Responsibilities

• Responds to patient billing and statement inquiries in a timely manner and follows the Patient Centered Medical Home guidelines when interacting with all patients to provide quality coordination of care.
• Makes recommendations to management for write-offs.
• Contacts patients regarding outstanding balances.
• Establishes payment plans to help patients manage payment of bills.

Supervisory Responsibilities

Competencies

• To perform the job successfully, an individual should demonstrate the following competencies:
• Use of Technology - Adapts to new technologies; uses technology to increase productivity; keeps technical skills up to date.
• Customer Service - Manages difficult or emotional customer situations; responds promptly to customer needs; solicits customer feedback to improve service; responds to requests for service and assistance; meets commitments.
• Communications - Expresses ideas and thoughts verbally; expresses ideas and thoughts in written form; exhibits good listening and comprehension; keeps others adequately informed; selects and uses appropriate communication methods.
• Diversity - Shows respect and sensitivity for cultural differences.
• Ethics - Treats people with respect; inspires the trust of others; works with integrity and principles; upholds organizational values.
• Personal Appearance - Dresses appropriately for position; keeps self well groomed.
• Attendance/Punctuality - Is consistently at work and on time; ensures work responsibilities are covered when absent; arrives at meetings and appointments on time.
• Safety and Security - Observes safety and security procedures; reports potentially unsafe conditions; uses equipment and materials properly.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience

• High School Diploma required.
  • Associate degree in a related medical or business field preferred.
  • Accounting or completion of accounting I or II preferred but not required, or equivalent combination of education and experience.
• 2-4 years’ experience in an outpatient clinic environment and/or a combination of education and experience required.
• Must have experience with Managed Care contracts, Federal and State reimbursement criteria.
• Required knowledge of UB-04 and 1500 Claim forms, and third-party payor electronic remittance advice.
• Medical terminology and/or anatomy/physiology, ICD-10-CM coding training/workshop completion preferred.

Mathematical Skills

• Experience in account and number reconciliation preferred.
• Must have the ability to calculate discounts, interest, commissions, proportions, and percentages.
• Must compute rate, ratio, and percent.

Computer Skills

Certificates, Licenses, Registrations

CPC (Certified Professional Coder) credential from the AAPC or one year certificate from college or technical school preferred but not required.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear. The employee is occasionally required to stand; walk and reach with hands and arms. The employee must frequently lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.