Overview 

The Clinical Billing Specialist is an experienced clinical Medicaid/MCO billing professional that supports the agency’s financial health and overall mission. As part of the Finance department, this role will provide critical review and auditing functions to our billing processes, helping to ensure an effective and efficient method of reimbursement.

Key Role Responsibilities 

• Perform a variety of billing functions, including charge and payment posting, processing of electronic EDI claims and electronic Explanation of Benefits (EOBs), tracking and follow-up on outstanding or denied claims, and receivable management tracking and reporting

• Review and audit critical billing and clinical information, such as EHR charts from multiple departments/specialties, E&M code levels and EHR documentation, diagnoses (represented by the ICD-9-CM coding, ICD-10-CM supporting the services provided, code levels supporting the complexity of the visit, and properly documented and coded CPT procedures

• Identify inaccurate coding services and subsequently prepares reports of findings to act as a catalyst for staff education and training on accurate coding practices and compliance issues

Key Agency Responsibilities 

In addition to role responsibilities, every staff member has the following responsibilities as a part of their employment:

• Models and reinforces the core values of dignity, authenticity, hope, justice, passion and balance

• Actively participates in performance improvement and advocacy activities that support the mission 

• Protects clients’ personal health information by maintaining compliance with HIPAA and other relevant health care-related IT security regulations

• Performs other duties on an as-needed basis

Knowledge, Experience, and Skills 

Formal Education and Training 

• Bachelor’s degree or equivalent experience

• Certified Professional Coder (CPC) certification preferred

Experience 

• Two (2) years or more billing experience in a health care setting

• Experience in and knowledge of Medicare/Medicaid payer guidelines

• Experience with GE Centricity Billing System and working with EMR a plus 

• Familiarity with insurance verifications and prior authorizations is required

• Experience working in a federally qualified health clinic (FQHC) is highly desirable

• Comfortable working with homeless and/or low-income individuals and families

Skills 

• Excellent interpersonal and customer service skills to interact and maintain relationships with a wide range of personalities

• Strong organizational skills necessary with strong accountability and drive

• Demonstrated proficiency with databases and spreadsheets

• Strong communication skills, both written and verbal

• Able to cope with interruptions, be flexible, and be a team player