Medical Revenue Cycle Billing Specialist

General Summary of Duties:

A medical revenue cycle billing specialist manages the revenue cycle of a healthcare facility by translating clinical procedures into billable claims. They are responsible for verifying insurance coverage, submitting claims to payers, resolving denied reimbursements, and processing patient invoices to ensure the practice receives timely and accurate payments. 

Essential Functions:

Functions include, but are not limited to the following:

• Insurance verification: Confirming patient eligibility, deductible status, and obtaining prior authorizations before medical services are rendered. 
• Claim Submission: Assembling data, including standardized medical codes like ICD-10 and CPT – to generate and submit clean claims to insurance carriers.  
• Payment Posting & Reconciliation: Recording payments received from insurance companies and patient into the billing software, if applicable.  
• Denial Management: Investigating rejected or underpaid claims, preparing appeals, and resubmitting claims to recover lost revenues. 
• Patient Billing: Understanding explanation of benefits (EOB) and the adjudication of the claim to interpret and explain the EOB benefits during billing inquiries.  
• Identifies possible problems with Electronic Data Interchange (EDI) transmissions from Athena to clearinghouse to carrier and reports problems and/or trends.  
• Participate in educational activities such as insurance seminars, Athena or billing entity updates and releases.  
• Any other duties assigned.

Education: 

High school diploma. Certified professional biller a plus. 

Experience: 

Experience navigating Electronic Health Record (EHR) platforms and computerized billing or clearinghouse systems. Athenahealth experience a plus. 

Knowledge of: 

• CPT, ICD-10, and HCPCS coding rules and application. 
• Medicare/Medicaid and third-party billing regulations. 
• Medical terminology. 

Skilled in: 

• Verbal and written communication. 
• Attention to detail and accuracy. 
• Problem solving analytics. 

Ability to: 

• Establish and maintain effective relationship with staff at all levels. 
• Handle sensitive and confidential patient information in a professional manner. 
• Maintain HIPAA Compliance Regulations.

Environmental/Physical/Working Conditions: 

• Office setting. Minimal exposure to communicable diseases. 
• Sitting 6-8 hours daily using a computer terminal. 
• Requires manual dexterity, hand-eye coordination using a calculator and computer keyboard. 
• Occasional stress during deadline periods. 
• Occasional need to lift 25 pounds.