Ophthalmic Billing and E/M Coder

The Ophthalmic Billing & E/M Coding Specialist is responsible for accurately posting clinic and hospital charges, with a primary focus on ophthalmology‑related Evaluation & Management (E&M) coding. This role includes reviewing documentation from ophthalmologists, ensuring correct use of CPT and ICD‑10 codes specific to ophthalmic services, drafting appeals for denied claims, assisting patients with understanding their accounts, and payment posting.

Essential Job Functions

• Accounts Receivable (A/R):Monitor and follow up on aging reports to reduce outstanding, delinquent balances for both patients and insurance.

• Denial Management: Review and appeal denied rejected claims communicating directly with insurance payers. 
• Verify coding accuracy by reviewing provider documentation against ophthalmology‑specific coding guidelines, payer rules, and reference materials.
• Communicate with providers when documentation, dictation, or coding information is missing or unclear.
• Meet regularly with the Billing Supervisor to review and resolve coding questions, documentation issues, and payer‑specific challenges.
• Draft well‑supported appeal letters to insurance carriers for denials related to coding, documentation, or medical necessity, especially for ophthalmic services and diagnostic testing.

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  Patient Inquiries:Resolve patient billing questions, manage account statements, and collect payments.
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  Claims Submission:Electronically submit claims to insurance carriers, ensuring accurate coding for ophthalmology-specific procedures (e.g., cataract surgery, injections, OCT scans).
• Payment Posting:Accurately post payments from insurance (ERAs/EOBs) and patients to their respective accounts.

• Compliance: Ensure all billing activities adhere to HIPAA regulations and specific payer guidelines.
• Participate in staff meetings and continuing education, including ophthalmology‑specific coding updates and compliance training.
• Promote clear and professional communication with clinical staff, providers, and coworkers.
• Aid coworkers and support team workflows as needed.
• Maintain a safe, organized, and clean work environment.
• Exhibit a professional and courteous appearance and demeanor appropriate for a patient‑care setting.

Requirements & Qualifications:

To perform this role successfully, individuals must be able to perform each essential function satisfactorily. Reasonable accommodation may be provided for individuals with disabilities.

• Minimum of a high school diploma or equivalent.
• 2-5 years of medical billing experience, with preference for ophthalmology or surgical specialties.
• Proficiency in CPT, ICD-10, and modifiers, specifically regarding global surgery policies. Familiarity with surgical billing, global periods, and Medicare/Medicaid/Medi-Cal rules.
• Vast knowledge of Medical terminology.1
• Strong interpersonal skills, with the ability to communicate clearly and professionally with physicians and staff.
• Experience with EMR/billing systems such as Practice , MoD MED, TriZetto, and Availity.
• Excellent organizational skills and a high level of accuracy, especially in reviewing documentation and entering charges.
• Strong attention to detail, analytical skills, and communication capabilities for handling patient and payer inquiries.
• Ability to read and create reports, checklists, and correspondence, and to understand complex written instructions. Excel knowledge a plus.
• Strong analytical skills with the ability to perform calculations and review detailed coding data quickly and accurately.
• Ability to apply common sense and sound judgment to resolve routine problems based on standardized procedures.
• Must be a self-motivated multi-tasker.
• Bi-Lingual is a plus