Mount Sinai Careers
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PROCEDURAL BILLING SPECIALIST III - OTOLARYNGOLOGY
The Procedural Billing Specialist III is a senior level individual, responsible for multiple components of the billing process for specialized or complex pre and post-surgical procedures, including coding, Accounts Receivable, Charge Entry, Edits and Payment Posting. Facilitates claims processing for services rendered by physicians. Assists with responses to problems or questions on benefit eligibility and reimbursement procedures. Independently engages or participates in the negotiation process with third party carrier Medical Directors and other representatives. Coordinates activities related to data entry of billing; performs staff training. Demonstrates proficiency in analysis and problem resolution to ensure accurate and timely payment of claims and collection. Maintains open dialogue with the Department Administrator or Manager on billing activity and current concerns.
Duties and Responsibilities:
- Performs specialized coding services for complex or more specialized inpatient and outpatient medical office visits. Reviews physician coding and provides updates.
- May provide financial counseling to patients, discussing the details concerning their insurance coverage and financial implications of out-of-network benefits, including pre-determination of benefits, appeals and/or pre-certification limitations. Develops and manages fee schedules and for self pay patients.
- Identifies submitted and required documentation to maximize revenue capture.
- Processes Worker’s Compensation claims and addresses/resolves all discrepancies.
- Conducts specialized negotiations with insurance companies, including engagement with Medical Directors and other relevant parties. Establishes a network of key representatives within the insurance pre-certification units to establish open lines of communication for future service negotiation.
- Manages or participates in the appeals process for claims as required.
- Verifies insurance and registration data for scheduled office, outpatient, and inpatient procedures. Reviews encounter forms for accuracy. Responsible for obtaining pre-certifications for scheduled admissions.
- Enters or oversees the accurate entry of office, inpatient, and/or outpatient charges. Runs and works missing charges, edits, denials list and processes appeals. Posts denials on a timely basis.
- Provides comprehensive denial management to facilitate cash flow. Tracks, quantifies and reports on denied claims.
- Directs and assists with responses to problems or questions regarding benefit eligibility and reimbursement procedures.
- Works credit balance report to ensure adherence to government regulations/guidelines.
- Analyzes claims system reports to ensure underpayments are correctly identified and collected from key carriers. Reviews and resolves billing issues and provides recommendations. Researches unidentified or misdirected payments.
- Identifies and resolves credentialing issues for department physicians.
- Reviews and distributes coding-related information to clinical staff, including CPT and ICD-9/10 code changes, medical necessity policies, coding/billing information on new procedures and devices.
- Trains and mentors less experienced billing staff. Assists area Manager in staff training initiatives.
- Maintains currency in profession on reimbursement trends, coding updates, etc.
- Other duties as assigned.
Associates Degree, or high school diploma/GED.
10 years experience in medical billing or health claims, with experience in billing systems in a health care or insurance environment, and familiarity with CPT/ ICD-9/10 coding, preferably in specialized and complex surgical procedures.
Excellent organizational skills
Excellent communication and customer service skills
Knowledge of medical terminology and anatomy
Strong attention to detail and ability to multitask
Excellent calculation, verbal and communication skills
Strong ability in analysis and research