Clinical Billing Specialist

Overview

A healthcare organization is seeking a full-time Clinical Billing Specialist to support the Care Management department. This role is Monday through Friday during daylight hours and is eligible for remote work from home.

Responsibilities

• Appeal payer denials as requested.
• Coordinate payor audits, conduct post-audit reviews to validate auditor findings, identify unbilled services, and negotiate final outcomes with payors.
• Keep management informed of the status of all assignments.
• Communicate and collaborate with physicians, physician office personnel, associates, care managers, third-party payer review personnel, and others to expedite billing and accounts receivable processes.
• Assist in monitoring, reporting, and developing process improvement initiatives to ensure regulatory compliance.
• Perform Charge Description Master (CDM) maintenance tasks promptly.
• Maintain contact with ancillary department managers to obtain information on price estimates and resolve charge issues.
• Retrieve, review, and release medical records according to defined functional area guidelines.
• Assist clinical staff in advocating for payor policy changes related to new or innovative care approaches.
• Support the development of Continuous Quality Improvement (CQI) initiatives within Patient Business Services (PBS).
• Maintain department productivity levels.
• Assist in clearing claims for billing as needed.
• Respond to billing inquiries and complaints requiring clinical understanding.
• Interpret third-party payor contract requirements and recommend, design, and implement procedures to ensure compliance.
• Adhere to organizational and departmental standards of conduct and policies.
• Understand utilization management as it relates to the continuum of care.
• Compare clinical findings with payor requirements, educate physicians on requirements, and obtain supporting documentation to substantiate medical appropriateness.

Requirements

• Minimum of 5 years of varied nursing experience.
• At least 3 years of experience in a healthcare financial environment preferred.
• Bachelor of Science degree in a healthcare-related field or Business Administration preferred.
• 2-5 years of patient account experience preferred.
• Familiarity with Medipac system and proficiency with PC word processing, spreadsheet, and database software preferred.
• Strong knowledge of CPT-4 and revenue coding preferred.
• Knowledge of SI/IS criteria for commercial, Medicare, and Medicaid insurance products to substantiate resource use and ensure compliance with third-party contracts.
• Must have Act 34 clearance.

Compensation & Benefits

Details regarding compensation and benefits are not specified.

Location

This position is eligible for remote work and requires availability during standard weekday daylight hours.