About This Role
Managing the medical billing and coding process to ensure accurate claim submission, timely reimbursement, and compliance with healthcare regulations is the core of this specialist role. It requires strong knowledge of medical terminology, coding standards, insurance billing procedures, and revenue cycle management. The specialist will review clinical documentation, validate coding accuracy, investigate claim denials, and resolve billing discrepancies.
Responsibilities
- Review medical records, clinical documentation, and provider notes to determine appropriate diagnosis and procedure codes
- Assign and validate ICD-10-CM, CPT, and HCPCS codes in accordance with current coding guidelines
- Ensure coding accuracy, medical necessity, and appropriate documentation support
- Identify coding discrepancies, missing information, and documentation gaps
- Collaborate with providers and clinical staff to obtain clarification when necessary
- Stay current with coding updates, payer policies, and applicable regulatory requirements
- Prepare, review, and submit clean claims to commercial insurers, Medicare, Medicaid, and other applicable payers
- Verify patient demographics, insurance eligibility, benefits, authorizations, and referral requirements
- Review claims for coding, billing, and reimbursement accuracy before submission
- Process electronic and paper claims according to payer specifications
- Ensure claims are submitted within established filing deadlines
- Investigate billing discrepancies and coordinate corrections to prevent avoidable denials
- Analyze rejected and denied claims to identify root causes and recurring billing issues
- Prepare and submit corrected claims, reconsiderations, and appeals within required deadlines
- Follow up on unpaid, underpaid, and outstanding insurance claims
- Research reimbursement discrepancies and contractual adjustments
- Maintain accurate accounts receivable records and document follow-up activities
- Recommend process improvements to reduce denials and accelerate collections
- Review and post insurance payments, patient payments, adjustments, and contractual write-offs
- Reconcile electronic remittance advice (ERA) and explanation of benefits (EOB) information
- Identify payment variances, duplicate payments, and potential underpayments
- Escalate discrepancies requiring additional investigation or management review
- Maintain compliance with HIPAA privacy and security requirements and applicable healthcare billing regulations
- Follow official coding guidelines, payer-specific policies, and organizational procedures
- Support internal audits, coding reviews, and billing quality assurance initiatives