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.