Healthcare Outcomes Performance Co. (HOPCo)

Authorization Specialist

• Monitors the authorizations of upcoming surgical cases on the physician’s calendars ensuring authorizations for surgeries are obtained in a timely and accurate manner.
• Verifies patient demographic information and insurance eligibility including coordination of benefits; updates and confirms necessary information to allow processing of claims to insurance plans.
• Completes surgical cost analysis form, documenting the required surgical cost estimation for collection prior to services.
• Verifies benefits on all surgical procedures.
• Document authorizations and progress of authorizations in the patient’s chart.
• Enters the authorization information within case management.
• Must be able to communicate effectively with physicians, patients, and co-workers and be capable of establishing good working relationships with both internal and external customers.
• Participate in providing ongoing training and education of staff as it relates to new processes to ensure timely confirmation of surgical cases.
• Work with the department manager to respond to and reduce complaints timely and professionally.
• Assist surgery schedulers with STAT authorizations.
• Ensure strict confidentiality of all health records, member information and meet HIPAA guidelines.
• Assists in identifying opportunities for improvement within the daily workflow process.
• Attends department meetings as required.

Surgical Authorization Specialist

Medical Billing and Coding

• Reviews and abstracts clinical documentation from complex inpatient orthopedic and spine surgery records to assign accurate ICD-10-CM, ICD-10-PCS, DRG, POA, and discharge disposition codes.
• Independently codes high-acuity inpatient orthopedic spine surgery cases including cervical, thoracic, and lumbar procedures, revisions, fusions, instrumentation, and neurological-related musculoskeletal procedures.
• Provides real-time feedback and training for coding staff to improve coding quality and productivity.
• Applies and validates accurate MS-DRG assignments while ensuring compliance with CMS, UHDDS, Official Coding Guidelines, and payer-specific requirements.
• Identifies coding trends, documentation gaps, and reimbursement risks and communicates findings to leadership.
• Maintains productivity and quality standards while managing high-volume and high-complexity inpatient workloads.
• Serves as a coding resource and mentor to less experienced coders and assists with onboarding and education initiatives.
• Participates in policy development, coding guideline interpretation, and implementation of regulatory updates.
• Acts as a liaison between coding staff, leadership, and external stakeholders.
• Supports coding audits, denials management, appeals, and quality improvement activities as assigned.

Inpatient Surgical Coder – PRN

Medical Director

• Provides physician leadership and clinical oversight for all MSK value-based care initiatives
• Collaborates with value-based care managers and network managers
• Oversees clinical strategies aligned with organizational quality and cost-management goals
• Guides evidence-based clinical decision-making
• Supports deployment of standardized care pathways and clinical protocols
• Educates and supports providers on improvement strategies

Regional Medical Director – Value Based Care

Revenue Operations

• Manages the day-to-day operations of the billing department to maximize net revenues and cash flow by managing all aspects of the revenue cycle while ensuring adherence to policies and procedures.
• Monitor accounts receivable activity and initiates appropriate corrective measures as needed.
• Communicates performance data and associated action plans to Senior Leadership.
• Identifies and implements processes to achieve key revenue cycle metrics including but not limited to A/R days, unbilled a/r, denial percentage, and cash collections.
• Analyze large volumes of data and provide financial analysis and regularly presents trends, movements, and status to Senior Leadership.
• Review billing work queues regularly to ensure that workloads are distributed evenly and that the department metrics are being met.
• Resolve complex patient, physician, and other issues when necessary.
• Manages self-pay receivables including vendor relationships to help resolve AR.
• Develop and implement policies and procedures for designated areas; evaluate new systems and methods and recommend changes as necessary.
• Communicate with payers and know when and how to escalate payer issues.
• Oversee the hiring, training, and supervision of department personnel.
• Maintains comprehensive knowledge of 3rd party billing requirements and reimbursement principles.
• Conducts regular meetings with staff to discuss third-party reimbursement methodologies.
• Keeps abreast of compliance regulations, standards, and directives regarding governmental/regulatory agencies and/or third party payers.
• Research and resolve discrepancies in a timely manner.
• Works with sensitive and confidential materials and must be able to exercise discretion.
• Verifies and updates patient registration information in the practice management system.

Revenue Cycle Manager

General

• Has an understanding of accounts receivable posting process for medical billing including: charges, payments, and adjustments.
• Posting financial transactions through use of the automated systems and team processes.
• Accurately interprets insurance explanation of benefits to ensure proper posting.
• Retrieves and uploads 835 remittance files into patient account system ensuring file reconciliation including reviewing and posting exception files.
• Participation in optimizing productivity within the area.
• Maintains knowledge of the work area and optimizes use of available technology.
• Researches all information needed to process and complete insurance and/or patient refunds by obtaining information from providers, insurance plans, ancillary services staff and patients.
• Accurately processes insurance and patient refunds requests by demonstrating an advanced understanding of coordination of benefits and eligibility requirements.
• Receives and processes all refunds utilizing insurance contracts and requirements for accuracy.
• Processes and posts refund checks as received into the patient accounting system.
• Establishes and maintains effective communication with physicians, staff and other departments as required.
• Other duties as assigned by leadership.
• Adheres and understands the Business Office rules and regulations in regards to Medicare and HIPAA guidelines.
• Effectively forwards accounts requiring work up or resubmission to the business office staff.
• Maintains productivity and accuracy metrics per department expectations and AEIOU Behavioral Standards.

Payment and Reconciliation Specialist

Billing Specialist

• Maintains productivity and accuracy metrics per department expectation and AEIOU Behavioral Standards.
• Abstracts data from medical records to ensure proper coding of diagnosis and procedures including any applicable modifiers.
• Reviews insurance denials and rejections to determine next appropriate action steps and obtain necessary information to resolve any outstanding denials/rejections.
• Updates and confirms as necessary to allow processing of claims to insurance plans.
• Researches all information needed to complete billing process including obtaining information from providers, ancillary services staff and patients.
• Attaches referrals/authorizations to appointments/charges if available.
• Maintains satisfactory productivity rates and ensures the timeliness of claims reimbursement while maintaining work queue goals.
• Makes and receives calls to/from patients to collect on self-pay balances and any other outstanding balance.
• Councils patients face to face when patients have questions or concerns regarding outstanding balances.
• Acts as a resource to staff and providers including providing subject matter expert education on billing and coding guidelines.
• Completes daily requests and working through obstacles on account balance to ensure maximum reimbursement.
• Identifies and communicates trends and/or potential issues to management team.
• Follows and maintains all CORE Institute policies and procedures, including those specific to billing and the Business Office.
• Other duties as assigned by leadership.

Site Billing Specialist – CPC, CCS, RHIT, RHIA Certification

• Maintains productivity and accuracy metrics per department expectation and AEIOU Behavioral Standards
• Abstracts data from medical records to ensure proper coding of diagnosis and procedures including any applicable modifiers
• Reviews insurance denials and rejections to determine next appropriate action steps
• Updates and confirms necessary information to allow processing of claims to insurance plans
• Researches all information needed to complete billing process including obtaining information from providers, ancillary services staff and patients
• Maintains satisfactory productivity rates and ensures the timeliness of claims reimbursement

Site Billing Specialist – CPC, CCS, RHIT or RHIA Certification

• Has an understanding of the accounts receivable posting process for medical billing including charges, payments, and adjustments.
• Posting financial transactions through the use of automated systems and team processes.
• Accurately interprets insurance explanation of benefits to ensure proper posting.
• Retrieves and uploads 835 remittance files into patient account system ensuring file reconciliation including reviewing and posting exception files.
• Participation in optimizing productivity within the area.
• Maintains knowledge of the work area and optimizes the use of available technology.
• Researches all information needed to process and complete insurance and/or patient refunds by obtaining information from providers, insurance plans, ancillary services staff, and patients.
• Accurately processes insurance and patient refund requests by demonstrating an advanced understanding of the coordination of benefits and eligibility requirements.
• Receives and processes all refunds utilizing insurance contracts and requirements for accuracy.
• Processes and posts refund checks as received into the patient accounting system.
• Establishes and maintains effective communication with physicians, staff, and other departments as required.
• Accepts and completes additional requests from the Cash Applications Supervisor.
• Adheres and understands the Business Office rules and regulations in regards to Medicare and HIPAA guidelines.
• Effectively forwards accounts requiring work up or resubmission to the business office staff.

Accountant

• Execute month-end close activities across various accounting functions with precision and efficiency.
• Support special projects, process optimizations, and system enhancements to maintain scalable operations.
• Perform account reconciliations and variance analyses to ensure financial accuracy and actionable insights.
• Collaborate with cross-functional teams to align accounting processes and enhance operational accuracy.
• Identify and recommend improvements to policies, procedures, and controls with practical, innovative solutions.
• Adapt to evolving priorities while contributing positive energy to a collaborative team environment.
• Other duties as assigned

Senior Accountant

Insurance

• Review insurance denials to determine and take the next appropriate action steps to receive payment from the payor.
• Appeal claims that have been denied for no auth, medical necessity, etc.
• Verify receipt of claims with insurance plans to ensure timeliness of claims reimbursement.
• Assume full responsibility for reducing the accounts receivable of insurance balances by working through outstanding accounts.
• Communicating with payors through phone calls, emails, and payor portals.
• Process and take action on any written correspondence from insurance payors.
• Identify and trend reasons for claim denials.
• Resolve claim discrepancies reported by patients and other clinical departments.

Insurance Follow-Up Representative

• Reviews insurance denials and rejections to determine the next appropriate action steps and obtain the necessary information to resolve any outstanding denials/rejections.
• Verifies patient demographic information and insurance eligibility including coordination of benefits; updates and confirms as necessary to allow processing of claims to insurance plans.
• Verifies receipt of claim with insurance plans, determining the next appropriate action steps and timeliness of claims maximum reimbursement.
• Researches all information needed to complete the billing process including obtaining information from providers, ancillary services staff, and patients.
• Obtains and attaches referrals/authorizations to appointments/charges.
• Maintains productivity and accuracy metrics per department expectations and AEIOU Behavioral Standards.
• Assumes full responsibility for reducing the accounts receivable of insurance balances by working through outstanding accounts.
• Analyzes account for proper claims processing and payment posting through inquiries from patients or staff.
• Identifies and communicates trends and/or potential issues to the management team.
• Follows and maintains all HOPCo policies and procedures, including those specific to billing and the Revenue Cycle.

Insurance Follow Up, Medical Biller

• Reviews insurance denials and rejections to determine the next appropriate action steps and obtain the necessary information to resolve any outstanding denials/rejections.
• Verifies patient demographic information and insurance eligibility including coordination of benefits.
• Updates and confirms as necessary to allow processing of claims to insurance plans.
• Verifies receipt of claim with insurance plans.
• Determines next appropriate action steps and timeliness of claims maximum reimbursement.
• Researches all information needed to complete the billing process including obtaining information from providers, ancillary services staff, and patients.
• Obtains and attaches referrals/authorizations to appointments/charges.
• Maintains productivity and accuracy metrics per department expectations and AEIOU Behavioral Standards.
• Assumes full responsibility for reducing the accounts receivable of insurance balances by working through outstanding accounts.
• Analyzes account for proper claims processing and payment posting through inquiries from patients or staff.
• Identifies and communicates trends and/or potential issues to the management team.
• Follows and maintains all HOPCo policies and procedures, including those specific to billing and the Revenue Cycle.

Insurance Follow Up Representative

• Reviewing patient records, doctor's notes, and other relevant documentation to extract information about diagnoses, procedures, and treatments.
• Determine which diagnostic and procedural information is necessary for accurate coding of an authorization.
• Assign appropriate ICD-10, CPT, and HCPCS codes based on the information found in the medical records.
• Verifying the correctness of assigned codes, ensuring they align with coding guidelines and regulations, and identifying any discrepancies or errors.
• Communicating with physicians, clinical stakeholders and other teams such as surgical scheduling and authorization management to clarify any ambiguities in the documentation or coding.
• Ensuring the security and confidentiality of patient information as mandated by HIPAA.

Coding Specialist – Pre-Service

Customer Success Manager

• Serve as the primary RCM strategic partner for assigned markets and physician groups
• Monitor and analyze key performance indicators including charge lag, denial rates, AR aging, AR >90 days, and net collection rate
• Lead monthly and quarterly revenue cycle reviews with market leadership and providers
• Identify root causes of revenue leakage and assist in developing corrective action plans
• Drive reduction in controllable denials through payer-specific analysis and operational collaboration
• Partner with cross-functionally with key revenue cycle stakeholders to proactively identify and resolve issues impacting revenue integrity and reimbursement performance.
• Support new market onboarding and RCM ASA integrations
• Escalate systemic issues to executive leadership with proposed solutions
• Participate in cross-functional revenue cycle initiatives and performance improvement projects

Surgical Authorization Specialist

Inpatient Surgical Coder – PRN

Regional Medical Director – Value Based Care

Revenue Cycle Manager

Payment and Reconciliation Specialist

Site Billing Specialist – CPC, CCS, RHIT, RHIA Certification

Site Billing Specialist – CPC, CCS, RHIT or RHIA Certification

Payment and Reconciliation Specialist

Senior Accountant

Insurance Follow-Up Representative

Insurance Follow Up, Medical Biller

Insurance Follow Up Representative

Coding Specialist – Pre-Service

RCM Success Manager