Medical Billing/Coding Specialist

Job Summary

As a Billing & Coding Specialist, you are responsible for conducting the assigned billing department’s daily operations within the healthcare setting. This includes preparation and submission of claims to insurance companies, ensuring accuracy in billing processes, maintaining records, monitoring and conducting proper follow up with insurance companies, and all other duties as assigned. This position is critical to maintaining a healthy revenue cycle and providing excellent support to patients and providers.

Responsibilities:

Review medical records and documentation to assign appropriate ICD-10 (International Classification of Diseases, 10th Revision), CPT (Current Procedural Terminology), and DRG (Diagnosis-Related Group) codes for billing purposes

• Prepare and submit accurate claims to insurance companies using Electronic Medical Record (EMR) and Electronic Health Record (EHR) systems
• Follow up on unpaid or denied claims through effective medical collection strategies
• Demonstrate awareness of current coding guidelines, reimbursement requirements and regulations
• Maintain detailed and organized medical records, including documentation of coding decisions and billing transactions
• Collaborate with healthcare providers to clarify documentation discrepancies or incomplete records
• Stay updated on changes in medical terminology, coding standards (ICD-9, ICD-10), promote accurate claim submission and documentation practices

Billing Process:

• Prepare and participate in end-to-end billing process, including invoicing, insurance claim submissions, and patient statements.
• Complete all billing activities in a timely, accurate, and compliant manner.
• Respond to billing inquiries via phone and email and resolve discrepancies quickly and professionally.
• Reconcile billing accounts and partners with supervisor/management on monthly and weekly metrics.
• Collaborate with other departments (i.e. Providers, Nursing, Reception) to ensure smooth billing operations.

Insurance & Coding Coordination:

• Collaborate with Billing Supervisor to ensure accurate coding of services and that they align with insurance billing requirements.
• Verify insurance details and coverage via insurance portals before claims are submitted.

Accounts Receivable:

• Monitor accounts receivable, follow up on overdue payments, follow up on unpaid or denied claims.

Compliance and Regulatory Adherence:

·       Practice in compliance with relevant billing regulations, such as HIPPA, Medicare/Medicaid, and other healthcare-specific billing requirements.

·       Participate in audits and prepare for external audits as required by regulatory bodies or the organization.

Reporting & Analysis:

• Maintain organized financial records and documents to support reports, including but not limited to key metrics like revenue cycle performance, AR aging, and claim denial rates.

Problem Resolution:

·       Professionally and accurately participate in the investigation and resolution of billing issues, including denied claims, billing errors, and discrepancies in payments.

·       Escalate unresolved discrepancies to Billing Supervisor.

Collaboration & Communication:

·       Ensure smooth coordination of billing and revenue cycle processes through collaboration with other departments (insurance, clinical staff).

·       Communicate effectively with insurance providers, patients, and clinic team members to ensure accurate and timely resolution of billing issues.

Qualifications:

Education & Experience:

o   High School diploma or equivalent; Associate or Bachelor’s degree in Health Administration, Finance, Accounting, or related field preferred

o   Certified Professional Biller (CPB), Certified Medical Reimbursement Specialist (CMRS), Certified Coding Specialist (CCS) or other relevant credentials preferred

o   2+ years of experience in medical billing or healthcare revenue cycle preferred

o   Proficiency with billing software (e.g. EPIC), Microsoft Office (Excel, Word, etc.) and billing/accounting systems

o   Skilled or experience verifying insurance eligibility in online portals (UHC, Availity, Medicaid, etc.)

Skills & Competencies:

o   Exceptional communication and interpersonal skills, with the ability to work effectively with cross-functional teams, insurance providers, and patients

o   Strong knowledge of ICD-9/ICD-10 coding systems and CPT coding procedures

o   Familiarity with DRG classifications used for outpatient reimbursement processes

o   Experience working with EMR/EHR systems and medical records management software; EPIC

o   Excellent understanding of medical terminology, healthcare documentation standards, and billing regulations

o   Ability to interpret complex medical records accurately and assign correct codes efficiently

o   Strong attention to detail, organizational skills, and the ability to handle multiple tasks simultaneously

 Physical Requirements:

o   Position involves sitting at a desk for long periods of time and working with computers and office equipment.

o   Minimal physical labor; may require lifting up to 25lbs.

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