Position Summary:Responsible for maintenance of clinic professional charges including updating of procedure and diagnosis codes and associated fee schedule in the practice management system, analysis of reimbursement data to identify and resolve variances, and patient and insurance refunds.
Responsibilities/Accountabilities:
Fee Schedule Maintenance:
- Updates existing fee schedules with payer allowed amounts annually (or as necessary).
- Attaches new schedules to all providers, expiring old schedule.
- Monitors CMS & commercial payer websites and transmittals for regulatory changes in reimbursement policies.
- Revises Standard Fees to comply with federal & state billing regulations & guidelines.
Payment Variance Analysis:
- Run carrier variance reports and research payment inconsistencies identified.
- Corrects invalid allowed amounts in corresponding fee schedules.
- Appeal underpayment errors with carriers.
- Identifies & reports carrier trends to Director.
Insurance Overpayments/Refunds:
- Validates insurance overpayments in demand letters from carriers and refund requests from A/R reps, making appropriate account adjustments as needed.
- Runs monthly credit balance reports to identify patient overpayments, conveys funds when appropriate, and places account in refund status.
- Forwards refund requests to Finance Department staff with supporting documentation.
- Processes patient and insurance refund checks for mailing with appropriate claim reconsideration forms or explanation letter, verifying payee name and address.
- Analyzes overpayment trends and recommend corrective procedures.
Month End Process:
- Verifies all deposits have been posted into the practice management system and carries over those not posted to the new monthly spreadsheet.
- Runs unapplied reports for patients and insurance to reconcile accounts.
- Analyze key performance indicators (KPI’s) revenue cycle metrics identifying trends, creating and maintaining reports and dashboards for leadership and performing root cause analysis on revenue cycle issues.
Customer Service and Communications:
- Communicates with patients, insurance carriers and other outside entities in a professional manner. Identifies solutions and responds professionally to patient concerns, i.e., pleasant tone of voice, courteous language, etc. Uses appropriate grammar and demonstrates tact and diplomacy in patient interactions, by phone and in person.
- Diffuses negative situations with patients and maintains a pleasant and professional tone during stressful circumstances and heavy workload.
- Communicates with staff members in a professional, pleasant manner; Shares information relevant to work, no gossiping or disparaging remarks, accepts work without complaint or provides reasons why assignment is unmanageable, asks and answers questions related to improving department performance.
Teamwork:
- Works cooperatively with coworkers, providers, and management.
- Shares knowledge and insights with co-workers in a constructive manner.
- Willingly provides coverage to department, staying beyond scheduled ending time when clinic schedule demands it, volunteering to cover time off or unexpected absences, maintaining workflow in department without direct supervision.
- Addresses conflicts with person directly before involving manager or uninvolved peers.
- Is considerate of others with regard to taking breaks or meal periods, use of computer and telephone, and noise in department.
Policies and Procedures:
- Knows and complies with policies and procedures as enumerated in the Orthopedic One Employee Handbook and policies and procedures documents.
- Provides assistance and support to leadership in implementing policies and procedures as necessary.
- Actively participates in training, and conducting day to day work activity by adhering to all policies and procedures as enumerated in compliance and risk management programs.
Education, Experience, and Certification/Licensure Required:
High School Diploma or equivalent required. Previous medical billing experience, preferably in an orthopedic surgery specialty is required. Candidates must have current certification as a Certified Professional Coder. Proficiency with software including practice management systems and Microsoft Excel.
Knowledge, Skills, and Abilities:
Demonstrates general knowledge of medical terminology and human anatomy; Demonstrates knowledge of medical billing and coding, evidenced by designation of certified professional coder and relevant job experience; Demonstrates knowledge of insurance processes and reimbursement practices; Able to work with high volume of work while maintaining attention to detail and accuracy; Demonstrates excellent oral and written communication skills; Able to operate practice management system and other computer programs (i.e., use Windows operating system, conduct Internet searches, communicate by email, etc.); Able to operate a calculator to accurately perform basic math functions; Able to work cooperatively as a member of the billing department to meet the needs of internal and external customers; Able to troubleshoot and resolve problems reported by staff with the practice management system.
