Description:
• Carefully examine medical claims documentation, including medical records, bills, and supporting documents, to verify the accuracy and completeness of information submitted by healthcare providers.
• Apply appropriate coding guidelines (e.g., ICD-10, CPT, HCPCS) to ensure that diagnoses, procedures, and services are correctly coded, in accordance with industry standards and regulatory requirements.
• Validate the appropriateness of claims based on established policies, contracts, and medical guidelines. Identify any discrepancies or inconsistencies and appropriately communicate them for further investigation.
• Identify and investigate potential billing errors, such as duplicate claims, unbundling, upcoding, and incorrect coding combinations. Report findings to the Claims Manager or designated supervisor.
• Monitor claims processing activities to ensure adherence to legal and regulatory requirements, such as HIPAA, CMS guidelines, and contractual obligations.
• Document audit findings, maintain accurate records, and generate comprehensive reports summarizing audit results, trends, and recommendations for process improvement.
• Collaborate with internal stakeholders, including claims processors, billing specialists, and healthcare providers, to resolve claim-related issues, provide guidance on coding requirements, and address any questions or concerns.
• Stay up-to-date with changes in coding guidelines, industry regulations, and best practices. Participate in training sessions and professional development activities to enhance knowledge and skills.
• Assist in the implementation and maintenance of quality assurance processes to ensure the accuracy, integrity, and efficiency of claims processing operations.
• Contact providers to obtain additional information and/or documentation to resolve unpaid claims, as directed.
• Respond to carrier telephone, fax and e-mail inquiries regarding outstanding claims
• Confer with carriers by telephone or use portals/web sites to determine member eligibility and claim status.
• Update case management system with proper noting of actions and appeal/denial information.
• Generate form letters to carriers to affect payment of outstanding claims.
• Leverage RCM knowledge to assess denials, pursue appeals or close claims when appropriate.
• Work with document imaging system for processing purposes.
• Responsible for achieving high recoveries against a portfolio of claims.
• Responsible for achieving daily, monthly, and quarterly quality and productivity KPIs.
Non-Essential Responsibilities
• Performs other functions as assigned
Knowledge, Skills and Abilities
• Proven experience in medical claims processing, medical billing, or coding, preferably in an auditing capacity.
• Strong understanding of third-party billing and/or claims processing.
• Strong knowledge of medical terminology, anatomy, physiology, and ICD-10, CPT, and HCPCS coding systems.
• Familiarity with healthcare regulations, including HIPAA, CMS guidelines, and insurance policies.
• Proficient in using medical billing software and coding databases.
• Excellent analytical and problem-solving skills with a keen attention to detail.
• Effective communication skills, both verbal and written, to interact with internal teams and external stakeholders.
• Ability to work independently, prioritize tasks, and meet deadlines.
• Strong ethical standards and understanding of confidentiality requirements.
• Continuous learning mindset and willingness to stay updated with industry changes.
• Ability to perform basic mathematic calculations.
• Ability to work proficiently with Microsoft Windows, Word and have intermediate level knowledge of Excel.
• Average manual dexterity in use of a PC, phone, sorting, filing and other office machines.
• Ability to perform well in team environment, with staff at all levels, to achieve business goals.
• Possess excellent customer service skills.
• Ability to work independently to meet predefined production and quality standards.
Work Conditions and Physical Demands
• Primarily sedentary work in a general office environment
• Ability to communicate and exchange information
• Ability to comprehend and interpret documents and data
• Requires occasional standing, walking, lifting, and moving objects (up to 10 lbs.)
• Requires manual dexterity to use computer, telephone and peripherals
• May be required to work extended hours for special business needs
• May be required to travel at least 10% of time based on business needs
Minimum Education
• High School Diploma or equivalent required.
• Some college coursework (with concentration in healthcare, medical billing or coding field) or a degree in a related field is preferred. Associates Degree Preferred.
Certifications (Required/Desired)
• Certification in medical billing/coding (e.g., CPC, CCS) is preferred
Minimum Related Work Experience
• 5-7 yrs. experience with third party collections
• 3yr experience handling appeals claims in hospital setting, Ability to interpret an Explanation of Benefits (EOB) and UB-04 claim form required. DSM-IV, CPT, HCPCS, and CMS-1500 preferred