The Procedural Billing Specialist I is responsible for multiple components of the complex billing and coding process for specialized procedures, including Accounts Receivable, Charge Entry, Edits and Payment Posting. This individual facilitates claims processing and payments services rendered by physicians and assists with responses to problems or questions regarding benefit eligibility and reimbursement procedures. S/he coordinates activities related to data entry of billing, and demonstrates proficiency in analysis and problem resolution to ensure accurate and timely payment of claims and collection. The Specialist works directly with the Department Administrator. Reports to Billing Manager/Revenue Cycle Manager.

Responsibilities

1. Performs specialized coding services for inpatient and outpatient medical office visits. Reviews physician coding and provides updates.

2. Provides comprehensive financial counseling to patients. Responsible for setting patient expectations, discussion of financial options, payment plans, one-time settlements and resolution of unpaid balances.

3. Discusses with patients the details concerning their insurance coverage and financial implications of out-of-network benefits, including pre-determination of benefits, appeals and/or pre-certification limitations.

4. Develop and manages fee schedules and for self-pay patients.

5. Processes Workers Compensation claims and addresses/resolves all discrepancies.

6. Conducts specialized negotiations with insurance companies. Brokers and negotiates with insurance carriers. Establishes a network of key representatives within the insurance pre-certification units to establish open lines of communication for future service negotiation.

7. Verifies insurance and registration data for scheduled office, outpatient, and inpatient procedures. Reviews encounter forms for accuracy. Responsible for obtaining pre-certifications for scheduled admissions.

8. Enters office, inpatient, and/or outpatient charges with accurate data entry of codes.

9. Posts all payments in IDX. Runs and works missing charges, edits, denials list and processes appeals. Posts denials in IDX on a timely basis.

10. Provides comprehensive denial management to facilitate cash flow. Tracks, quantifies and reports on denied claims.

11. Directs and assists with responses to problems or questions regarding benefit eligibility and reimbursement procedures.

12. Researches unidentified or misdirected payments.

13. Works credit balance report to ensure adherence to government regulations/guidelines.

14. Analyzes claims system reports to ensure underpayments are correctly identified and collected from key carriers. Reviews and resolves billing issues and provides recommendations.

15. Identifies and resolves credentialing issues for department physicians.

16. Maintains a thorough understanding of medical terminology through participation in continuing education programs to effectively apply ICD-10-CM/PCS, CPT and HCPCS coding guidelines to inpatient and outpatient diagnoses and procedures.

17. Meets with practice management, leadership and/or physicians on a scheduled basis to review Accounts Receivable and current billing concerns.

18. Mentors less experienced billing staff and assists Billing Manager/Revenue Cycle Manager in staff training.

19. Other identified duties as assigned.

Qualifications

• Associates Degree preferred
• 5 years experience in medical billing or health claims, with experience in IDX billing systems in a health care or insurance environment, and strong familiarity with ICD/CPT coding
• Licensing: None but CPC strongly preferreding (e.g., CPC) is preferred but not required.

Job Type: Full-time

Pay: $58,661.00 - $81,675.00 per year

Benefits:

• Dental insurance
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Work setting:

• Hospital
• Office

Education:

• Associate (Preferred)

Experience:

• Medical billing: 5 years (Required)

Work Location: In person