Medical Billing and Coding

• Coordinate/review the work of subordinate employees and assist with the training and continuing education programs.
• Code medical records utilizing ICD-10-CM and CPT-4 coding conventions.
• Review the medical record to ensure specificity of diagnoses, procedures, and appropriate/optimal reimbursement for hospital and/or professional charges.
• Abstract information from medical records following established methods and procedures.
• Review the complex (problematic coding that needs research and reference checking) medical records and accurately code the primary/secondary diagnoses and procedures using ICD-10-CM and/or CPT coding conventions.
• Ensure quality and quantity of work performed through regular audits.
• Assist with research, development, and presentation of continuing education programs in areas of specialization.
• Sequence the diagnoses and procedures using coding guidelines.
• Ensure DRG/APC assignment is accurate.
• Abstract and compile data from medical records for appropriate optimal reimbursement for hospital and/or professional charges.
• Consult with and educate physicians on coding practices and conventions in order to provide detailed coding information.
• Communicate with nursing and ancillary services personnel for needed documentation for accurate coding.
• Maintain a thorough understanding of anatomy and physiology, medical terminology, disease processes, and surgical techniques through participation in continuing education programs to effectively apply ICD-10-CM and CPT-4 coding guidelines to inpatient and outpatient diagnoses and procedures.
• Maintain a thorough understanding of medical record practices, standards, regulations, Joint Commission on Accreditation of Health Organizations (JCAHO), Health Care/Finance Administration (HCFA), Medical Review of North Carolina (MRNC), etc.
• Assist with special projects as required.
• Perform other related duties incidental to the work described herein.

Medical Records Coder II – Ophthalmology

• Evaluates medical records, provides clinical and surgical abstraction and assigns appropriate clinical diagnosis and procedure codes.
• Analyzes medical information from medical records
• Accurately codes diagnostic and procedural information in accordance with national coding guidelines
• Consults with medical providers to clarify missing or inadequate record information and to determine appropriate codes.
• Provides thorough, timely and accurate coding in accordance to department specific productivity and quality standards.

Profee Coder – Primary Care

• Assign and sequence ICD-10-CM, ICD-10-PCS, and CPT-4 codes for inpatient, outpatient, ambulatory, and emergency room records while ensuring accuracy for billing, reimbursement, and compliance
• Review medical records for DRG/APC assignment, verify charge accuracy, abstract clinical data, and collaborate with providers and hospital departments to ensure proper documentation and regulatory compliance
• Accurately reflects the diagnosis and procedures per department procedure within the medical records
• Proactively communicates with providers, staff, leadership and hospital departments to ensure adequate documentation to support services
• Performs Charge capture and data entry per department protocol and procedure
• Ensures accurate abstracting of clinical data and meets regulatory and compliance requirements

Certified Facility Coder

• The RCM Medical Billing Operations Supervisor position works under the supervision of the RCM Manager.
• Oversees the front end of the medical billing cycle, namely timely and accurate claim submission processes.
• Supervises the Coding and Claim Review Specialists and Medical Billing Assistant.
• Ensures acceptable resolution of failed claims in the EHR to promote timely submission of claims.
• Monitors unbilled claims and upfront rejections.
• Responsible for coding and mapping in the EHR, maintaining payer information, billing configurations, fee matrices, and rules for the claim engine.
• Performs RCM Billing Audits and may assist in running regular reports to track department goals and progress.
• Provides direct supervision to the Coding and Claim Review Specialists and Medical Billing Assistant, meeting regularly to provide guidance, direction, support, and resources necessary for efficient job performance.
• Conducts quarterly and annual performance evaluations and assists staff in establishing and achieving individual goals aligned with departmental objectives.
• Troubleshoots, investigates, and resolves failed claims within the claim management system daily to ensure timely claim submission and reimbursement.
• Configures, maintains, and monitors payer billing settings, procedure code, bill-next, and adjustment reason code mappings within billing systems.
• Applies proactive problem-solving, analytical thinking, and attention to detail to identify, research, and resolve billing, coding, and claim processing issues.

RCM Medical Billing Operations Supervisor

• Prepare, review, and submit clean medical claims to commercial payers.
• Verify claim accuracy, including coding, modifiers, eligibility, EAP authorizations, and provider details
• Monitor claim rejections and take timely corrective actions
• Manage denial resolution: research root cause, correct and resubmit, or prepare appeals
• Conduct proactive follow-up on outstanding A/R and aging claims
• Support patient billing activities and inquiries when needed
• Document all billing activities clearly and accurately in internal systems
• Ensure compliance with HIPAA, payer regulations, and state/federal billing guidelines
• Collaborate with credentialing, eligibility/benefits, clinical operations, and internal RCM teammates
• Identify trends and recommend process improvements to reduce denials and rework

Medical Billing Specialist

• Execute tasks focused on revenue generation through account resolution for any company client.
• Review documentation to support or contest payer coding decisions for multiple facilities.
• Prepare clear, concise, and well-supported appeals where applicable, using all available documentation, coding guidelines, and regulatory references to defend billed claims and secure reimbursement on insurance accounts receivable.
• Investigate the root causes of denials and downgrades, as needed.
• Provide targeted training on coding practices to Currance team members, promoting accuracy, compliance, and efficiency in resolving coding-related issues.
• Participate in daily shift briefings and contribute actively.
• Resubmit corrected claims according to Federal, State, and payer-mandated guidelines.
• Research, analyze, and correct claim errors and rejections to ensure accurate resubmission and to avoid payer denials due to preventable errors.
• Escalate problematic accounts, recurring issues, or trends to Supervisor and recommend education or denial prevention measures to the client.
• Stay current on payer updates, process changes, and coding guidelines to maintain compliance with Federal, State, and payer requirements.
• Meet productivity standards while maintaining quality output.
• Communicate payer-specific issues to the team and management for timely resolution.
• Engage in continuous learning to remain up to date on coding and payer policies.

Denial Resolution Specialist

• Conducts quality assurance coding of medical records and ICD-10 diagnosis codes
• Assumes ownership and leads advanced and highly specialized administrative/operational/customer support duties
• Ensures coding is accurate and properly supported by clinical documentation within the health record
• Reviews medical records to report conditions that map to HCCs
• Follows state and federal regulations and internal policies
• Works on projects that may include making phone calls to providers
• Participates on special projects, in addition to daily responsibilities

Risk Adjustment Coder

• Performs HCC coding on projects for MA, ACA, and End Stage Renal Disease (ESRD)
• Works independently in various coding applications
• Adheres to CMS Guidelines for Coding and Highmark’s Policy and Procedures
• Maintains RPM coding accuracy and productivity requirements
• Assists with Regulatory Audits by performing first coding review

HCC Coding Specialist

• Educates and supports Providers and staff by providing ongoing coding training
• Conducts random chart audits and provides direct feedback to providers
• Investigates and answers provider coding questions
• Reviews various data/reports and provides additional feedback
• Routinely visits Providence Medical Groups (PMG) clinics and attends clinical meetings
• Stays current with annual updates to CPT and ICD-10 and HCPCS codes.

Developer

• Accurately assigns appropriate ICD-10-CM and CPT-4 codes to outpatient records
• Abstract essential data elements for tracking, reporting, and reimbursement purposes
• Keying, billing and collections for assigned client databases
• Review and analyze medical records for document deficiencies
• Ensure accurate coding and compliance with Federal and State regulations
• Verify accuracy of patient account, type, and demographic data
• Meet productivity standards set by Revenue Integrity Coding department

Certified Professional Coder

• Accurately assigns diagnosis and procedure codes for inpatient facility and professional services.
• Performs necessary tasks within MHS GENESIS and other military coding systems.
• Accurately assign Evaluation and Management (E&M) codes, ICD-CM diagnoses, CPT and HCPCS, modifiers, and quantities derived from medical record documentation.
• Reviews encounter and/or record documentation to identify and resolve inconsistencies, ambiguities, or discrepancies.
• Assigns accurate codes based on provider responses to coding queries.
• Supports DHA coding compliance by performing due diligence in ethically and appropriately researching and/or interpreting existing guidance.
• Utilizes MHS computer systems to remotely access patient records and assign codes for patient encounters in support of other MTFs.
• Achieve and maintain DHA coding productivity and accuracy standards for the position.
• Educates and provides feedback to providers and clinical staff to resolve documentation issues to support coding compliance.
• Acts as a source of reference to medical staff having questions, issues, or concerns related to coding.
• Responds to provider questions and provides examples of appropriate coding and documentation reference(s).

Medical Coder II

• Coordinate/review the work of subordinate employees and assist with the training and continuing education programs.
• Code medical records utilizing ICD-10-CM and CPT-4 coding conventions.
• Review the medical record to assure specificity of diagnoses, procedures, and appropriate/optimal reimbursement for hospital and/or professional charges.
• Abstract information from medical records following established methods and procedures.
• Review the complex medical records and accurately code the primary/secondary diagnoses and procedures using ICD-10-CM and/or CPT coding conventions.
• Ensure quality and quantity of work performed through regular audits.
• Assist with research, development, and presentation of continuing education programs on areas of specialization.
• Maintain a thorough understanding of anatomy and physiology, medical terminology, disease processes, and surgical techniques through participation in continuing education programs.

Medical Records Coder II – Outpatient

• Reviews documentation and assigns appropriate ICD-10, CPT and HCPCS codes.
• Assigns appropriate primary diagnosis after deciding what was chiefly responsible for the encounter.
• Assigns appropriate modifiers according to guidelines.
• Finalizes the appropriate data for accounts.
• Clarifies documentation or diagnosis by communicating with the physician.
• Ensures weekly, monthly, and quarterly department goals are met.
• Makes recommendations to the Billing and Coding Manager for process and quality improvement.
• Maintains knowledge of current coding rules and trends for coding types assigned by attending seminars, workshops and watching webinars.

Medical Coder

• Educate and support Providers, Division Directors/Managers and clinical staff by providing ongoing coding training
• Conduct random chart audits and provide direct feedback to providers
• Investigate and answer provider coding questions
• Review various data/reports and provide additional feedback
• Routinely visit Providence Medical Groups (PMG) clinics and attend clinical meetings
• Stay current with annual updates to CPT and ICD-10 and HCPCS codes

Coder

• Support an environment that reinforces Rebound’s mission and Core Values of Superior Service, Teamwork, Integrity, Innovation, Quality and Recognition.
• Submit professional and facility claims electronically through Epic's module and clearinghouse interface.
• Validate claim data using Charge Review and Claim Edit work queues, correction errors prior to submission.
• Confirm insurance coverage, place of service, provider information, and coding accuracy prior to release.
• Resubmit corrected claims when needed and follow up on rejected or pended submissions.
• Work assigned Charge Review, Claim Edit, and Follow up work queues daily to ensure clean claims and timely payer responses.
• Route claims to coding or registration or contracting teams when discrepancies impact billing.
• Identify trends or repeat edit issues and escalate to management or system support for root cause resolution.
• Review payer rejections and denials in Epic and take appropriate action to correct and resubmit claims.
• Coordinate with insurance companies via web portals or phone calls to resolve claims issues.
• Document all actions taken in account notes to ensure audit trail and communication across teams.
• Follow all CMS and commercial payer billing guidelines, including NCCI edits, modifiers, and place of service requirements.
• Stay updated on payer-specific requirements for both professional and facility claims.
• Maintain knowledge of billing for multiple service lines, including E&M, surgical procedures and ancillary services.
• Maintain a high degree of confidentiality and abide by all HIPAA rules and regulations.
• Perform other duties as assigned.

Medical Billing Accounts Receivable Specialist – Temporary

• Reviews and interprets medical information, physician treatment plans, course, and outcome to determine appropriate ICD-10 CM/CPT codes for diagnoses and procedures. ( 65%)
• Abstracts data elements to satisfy statistical requests by the hospital, health system, medical staff, etc. and enters all coded/abstracted information into designated system. ( 15%)
• Ensures efficient management of medical information and cash flow as it pertains to the unbilled coding report. ( 10%)
• Keeps informed of the changes/updates in ICD-10 CM/CPT guidelines by attending appropriate training, reviewing coding clinics and other resources and implementing these updates in daily work. ( 5%)
• Performs other duties as assigned or required. (5%)

Coder – Outpatient

• Process claims to appropriate primary, secondary, and/or tertiary insurance company according to insurance guidelines
• Perform follow-up on unpaid insurance accounts identified through aging reports
• Process appeals when appropriate
• Process refund requests
• Identify trends, and carrier issues relating to billing and reimbursements, report findings to leadership
• Maintain Privacy & Confidentiality of patient information and organizational operations
• Responsible for learning, understanding and following payer guidelines
• Reallocate misapplied payments and adjustments
• Work special assignments when needed

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