Procedural Billing Specialist II-MSW-FT Days

Responsible for multiple components of the billing process for specialized or complex pre and post-surgical procedures,  including coding, Accounts Receivable, Charge Entry, Edits and Payment Posting.   Facilitates claims processing for services rendered by physicians.  Assists with responses to problems or questions on benefit eligibility and reimbursement procedures.     Independently engages or participates in the negotiation process with third party carrier Medical Directors and other representatives.   Coordinates activities related to data entry of billing and mentors less senior billing staff on coding and other items.   Demonstrates proficiency in analysis and problem resolution to ensure accurate and timely payment of claims and collection. Maintains open dialogue with the Department Administrator and/or Revenue Cycle Manager on billing activity and current concerns. 

1.   Performs specialized coding services for complex or more specialized 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.   Develops and manages fee schedules and for self-pay patients.

5.   Processes Worker’s Compensation claims and addresses/resolves all discrepancies.

6.   Conducts specialized negotiations with insurance companies, including engagement with Medical Directors and other relevant parties.    Establishes a network of key representatives within the insurance pre-certification units to establish open lines of communication for future service negotiation.

7.   Manages or participates in the appeals process for claims as required.

8.   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.

9.   Enters or oversees the accurate entry of office, inpatient, and/or outpatient charges.

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

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

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

13. Researches unidentified or misdirected payments.

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

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

16. Identifies and resolves credentialing issues for department physicians.

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 initiatives.

19. Maintains currency on reimbursement trends, coding updates, etc.

20. Other duties as assigned.

• MS Office Suite: Basic
• Training in computerized medical billing

1. Excellent organizational skills
2. Excellent communication and customer service skills
3. Knowledge of medical terminology and anatomy
4. Strong attention to detail and ability to multitask
5. Excellent calculation, verbal and communication skills
6. Strong ability in analysis and research