Medical Billing Representative - CPC Preferred

Summary of Position : The Accounts Receivable / Follow-up Specialist is an integral member of the reimbursement team and has primary responsibility to oversee follow-up activities for all third-party payers and assigned accounts. This includes collecting payments for outstanding insurance claims, researching denials, submitting appeals, claim resubmissions and ensuring payments received are reconciled correctly. Performs a variety of complex clerical and accounting functions for patient billing, including verification of encounter information, maintenance of insurance plan files, resolution of claims errors, rejections, and payer denials. Recreates and re-bills claims to insurance companies and other entities, prepares refunds, adjustments and write-offs, identifies accounts for appeals and coordinates cash posting activities with collection and cash posting staff. Additionally, as a Medical Biller and Coder, this role accurately converts patient diagnoses and procedures into alphanumeric codes (like ICD-10, CPT, and HCPCS) to submit and manage claims, ensuring accurate reimbursement from insurance companies and patients.

Primary Duties and Responsibilities :

A / R Follow Up & Appeals :

• Perform account follow-up on outstanding and denied insurance balances and take the necessary action for account full resolution. This includes making outbound calls to payers and / or accessing payer websites / portals.
• Collaborate with insurance payers to determine why claims have been denied and obtain the information required to expedite full reimbursement.
• Research CPT and ICD-10 coding correlation, CCI edits, contractual agreements, and Medicare billing guideline for each specific claim / case to ensure highest reimbursement.
• Prepare and submit reconsiderations forms and appeals processes in accordance to the payer requirements to substantiate claim reimbursement.
• Working from the accounts aging reports to meet or exceed daily claim follow-up productivity standards. Includes generating and analysis of aging summary report to determine the scope of the problem or denial trends requiring follow-up.
• Document all follow-up activity taken on an account in the account notes to ensure an audit trail.
• Review professional billing (1500) components for accuracy. Make necessary changes as required in accordance with billing laws.
• Works independently to analysis problem claims and process appropriate to resolve the account to full reimbursement.
• Ensures strict compliance to HIPPA requirements and Medicare compliance.
• Familiar with terms such as HMO, PPO, IPA and Capitation
• Understanding / ability to read an EOB

Medical Coder :

Ensuring that codes are assigned correctly and sequenced appropriately as per government and insurance regulations

Complying with medical coding guidelines and policies

Receiving and reviewing patients' charts and documents for verification and accuracy

Following up and clarifying any information that is not clear to other staff members

Collecting information made by the Physician from different sources to prepare monthly reports

Implementing strategic procedures and choosing strategies and evaluation methods that provide correct results

A strong understanding of physiology, medical terms and anatomy

General :

Ensures strict confidentiality of financial and medical records

Participate in development of organization procedures and update of forms and manuals.

Performs a variety of general clerical duties, including telephone reception, mail distribution, and other routine / miscellaneous functions as assigned.

Proficiency in computer skills including typing speed and accuracy

Mathematics skills

Excellent written and verbal communication skills

Organizational skills

Ability to maintain a high level of integrity and confidentiality of medical information

Strict attention to details

Knowledge of data entry

Assist other Billing Representatives and Management with a variety of other daily tasks

Respond to email, EHR messages / tasks throughout the day

Be a team player : Identify how you might assist fellow team members

Always represent SDCC and its staff and Providers in a professional, courteous, and respectful manner on or off the property

Position Requirements :

Certified Professional Coder (CPC) required

Minimum 1 years' experience that is directly related to the duties and responsibilities specified.

Understanding of HCFA-1500 & UB claims form and re-billing process.

Experience with medical coding guidelines and procedures such as ICD-9, CPT, ARG and ASA, among several others.

Knowledge of surgery, CPT and ICD-10 coding and billing.

Assertive and goal oriented.

Ability to communicate effectively both orally and in writing, often in stressful situations.

Superior customer service skills.

Ability to handle multiple tasks simultaneously under strict deadlines.

Proficiency in MS Windows and Office Suite

Cariology experience preferred

Position Specifics :

Full time

Monday-Friday

7 : 30 am to 4 : 30 pm (hours are flexible)

In-office; not a remote position