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.

The Clinical Billing Specialist acts as a clinical resource for all Patient Business Services areas, conducting charge audits, supporting patient billing inquiries requiring clinical review, and participating in continuous quality improvement (CQI) initiatives within the Patient Business Services area.

Responsibilities

• Appeal payer denials as requested.
• Coordinate payor audits, conduct post-audit reviews to validate findings, identify unbilled services, and negotiate final outcomes with payors.
• Keep management informed on the status of 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 CQI initiatives within Patient Business Services.
• 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 Patient Business Services standards of conduct.
• 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.
• Follow departmental policies and procedures.

Requirements

• Minimum of 5 years of varied nursing experience.
• At least 3 years of experience in a healthcare financial environment preferred.
• Act 34 clearance.

Preferred Qualifications

• Bachelor of Science degree in a healthcare-related field or Business Administration.
• 2-5 years of patient account experience.
• Familiarity with Medipac system and proficiency with PC word processing, spreadsheet, and database software.
• Knowledge of CPT-4 and revenue coding.
• Understanding of SI/IS criteria for commercial, Medicare, and Medicaid insurance products to substantiate resource use and ensure compliance with third-party contracts.

Location

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