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Medical Billing Auditor
3 months ago
At PCG Consulting Group, we are a leader in financial, recovery, insurance, and healthcare services based in Chicago. Our innovative solutions and commitment to excellence have positioned us as a trusted partner in the industry. We leverage cutting-edge technology and a data-driven approach to deliver outstanding results for our clients. Joining our team means being part of a dynamic environment that encourages professional growth and values each member's contribution.
The ideal candidate will have extensive experience in healthcare revenue cycle management, particularly in analyzing EDI transactions and ensuring zero balance accuracy across various financial systems. This role requires strong analytical skills, attention to detail, and the ability to collaborate with cross-functional teams to optimize revenue cycle operations.
Key Responsibilities:
- EDI Transaction Analysis:
- Analyze electronic claims submissions, remittance advice, and other EDI transactions to identify discrepancies, errors, and trends.
- Collaborate with IT and revenue cycle teams to troubleshoot EDI issues and ensure timely resolution.
- Develop and maintain EDI performance metrics to monitor transaction volume, rejection rates, and turnaround times.
2. Zero Balance Process Management:
- Oversee the zero-balance reconciliation process to ensure accurate posting of payments, adjustments, and denials.
- Implement best practices and controls to minimize zero balance variances and improve revenue integrity.
- Work closely with billing and collections teams to investigate and resolve discrepancies related to zero balance accounts.
3. Revenue Cycle Analysis:
- Conduct comprehensive analysis of revenue cycle data to identify opportunities for process improvement, cost reduction, and revenue enhancement.
- Generate reports and dashboards to present key performance indicators (KPIs) related to EDI, zero balance, and overall revenue cycle performance.
- Collaborate with stakeholders to develop and implement action plans based on analysis findings.
4. Compliance and Regulatory Compliance:
- Stay updated on healthcare regulations, payer policies, and industry trends related to EDI transactions and revenue cycle management.
- Ensure compliance with HIPAA, HITECH, and other relevant regulations governing electronic transactions and protected health information.
- Participate in audits and regulatory reviews related to revenue cycle processes and EDI transactions.
5. Team Leadership and Collaboration:
- Provide guidance and mentorship to junior analysts within the revenue cycle team.
- Foster a collaborative working environment by effectively communicating with cross-functional teams, including IT, finance, billing, and compliance.
- Lead or participate in revenue cycle improvement initiatives and projects
- Stay up to date on the latest industry regulations and coding standards related to healthcare revenue cycle management
- Lead and manage projects focused on accurate matching 835 remittance advices with corresponding 837 claims submission.
Additional Responsibilites:
- Extract and analyze 837 transaction files containing claims data submitted to Medicare.
- Match claims submitted to Medicare with corresponding payments received to verify accuracy.
- Conduct thorough reviews of claims to ensure compliance with Medicare billing regulations and guidelines.
- Identify and investigate discrepancies or errors in billing, such as overpayments, underpayments, or billing inaccuracies.
- Collaborate with internal teams to resolve billing discrepancies and ensure timely reimbursement.
- Document audit findings and prepare reports detailing any discrepancies or errors found during the audit process.
- Stay updated on changes in Medicare billing regulations and guidelines to ensure compliance.
- Provide recommendations for process improvements to enhance billing accuracy and efficiency.
- Bachelor's degree in healthcare administration, finance, business, or related field.
- Minimum of 3 years of experience in revenue cycle analyst with a focus on EDI transactions and zero balance reconciliation. (835/837)
- Strong understanding of healthcare billing, coding, and reimbursement methodologies.
- Proficiency in using revenue cycle management software and EDI transaction platforms.
- Excellent analytical and problem-solving skills, with the ability to interpret complex data sets.
- Strong communication skills, both verbal and written, with the ability to effectively interact with stakeholders at all levels.
- Demonstrated leadership capabilities and experience in leading cross-functional teams.
- Certified Professional Coder (CPC) or Certified Revenue Cycle Specialist (CRCS) certification preferred.
- Knowledge of healthcare compliance regulations and industry standards.
- Ability to adapt to changing priorities and work effectively in a fast-paced environment.
Additional Qualifications:
- Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification.
- Experience with Medicare Advantage and other government healthcare programs.
- Knowledge of ICD-10, CPT, and HCPCS coding systems.
- Experience working in a healthcare consulting or advisory role.
