Billing Specialist

This position is expected to have excellent reasoning skills based on knowledge of clinic operations as it pertains to billing claims to Insurance Health Plans, coding for medical diagnosis and procedural coding. Individual must be familiar with the conventions and instructions provided within the ICD disease classifications and CPT coding guidelines. Should also be able to reason through insurance claims differences as defined by benefit and plan differences. This position is responsible for resolution of A/R in a complete, accurate, and timely manner while verifying that industry rules and regulations, including, local, state, and federal regulations, regarding billing and collection practices are followed; as well as with established internal policy and procedure.

• Review medical record documentation to identify services provided by physicians and mid-level providers as it pertains to claims that are being filed.
• Verifies appropriate CPT, ICD, and HCPCS codes to accurately file claims for the physician service using the medical record as supporting documentation.
• Performs corrections for patient registration information that includes, but is not limited to, patient demographics and insurance information.
• Responsible for working EDI claim rejections in a timely manner.
• Receives and interprets Explanation of Benefits (EOB) that supports payments from Insurance Carriers, Medicare, or patients. Able to apply correctly to claims/ fee billed.
• Processes incoming EOBs to ensure timely insurance filing or patient billing. May require correction of data originally submitted for a claim or Coordination of Benefits with secondary insurance.
• Responsible for processing payments, adjustments and denials according to established guidelines.
• Responsible for reviewing insurance payer reimbursements for correct contractual allowable amounts.
• Responsible for reporting payer payment and denial trends in a timely fashion.
• Responsible for reconciling transactions to ensure that payments are balanced.
• Responsible for reducing accounts receivables by accurately and thoroughly working assigned accounts in accordance with established policy and procedures.
• Responsible for keeping current with changes in their respective payer’s policies and procedures.
• Communicates with the Clinics to provide or obtain corrected or additional data.
• Able to prepare documents for training or for establishing procedures for clinics.
• Identifies problems and root cause of problems related to billing and collections.
• Assist with training materials and training staff members.
• Responsible for identifying problems/trends in medical documentation and reporting them in a timely fashion.
• Answers patient and customer questions regarding billing and statements.
• Prepare claims for encounters with complex progress note issues.
• Participates in special assigned projects.

Minimum Required Education, Experience & Skills

• High school diploma or GED equivalent
• Strong attention to detail and professional customer service skills
• Proficiency with Microsoft Office applications

Preferred Education, Experience & Skills

• Two years of relevant medical experience; medical terminology and ICD/CPT coding preferred.
• Technical skills in the areas of EDI, systems analysis and process flows required.
• One or more years of related billing and/or collection experience required.
• Coding certification preferred but not required.
• 50wpm typing skill preferred.
• Knowledge of submission and resubmission of medical claims.
• Knowledge of government and commercial policies and procedures.
• Knowledge of ICD, CPT codes and HCPCS coding.
• Knowledge of HIPAA compliance rules and regulations.
• Skill in the operation of billing software and office equipment.

Physical & Mental Requirements:

• Ability to sit for extended periods of time
• Ability to stand for extended periods of time
• Ability to use fine motor skills to operate office equipment and/or machinery
• Ability to receive and comprehend instructions verbally and/or in writing
• Ability to use logical reasoning for simple and complex problem solving
• Ability to travel to multiple locations to support business needs as required