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
- Maintain accurate, complete, and confidential patient billing records
- Identify potential compliance risks and escalate concerns through appropriate channels
- Never knowingly submit inaccurate, unsupported, or noncompliant claims
- Monitor billing performance, claim acceptance, denial trends, and accounts receivable metrics
- Prepare routine reports on claim status, unresolved denials, and reimbursement issues
- Collaborate with providers, front-office staff, finance teams, and insurance representatives
- Provide guidance on billing workflows and coding requirements when appropriate
- Contribute to process improvement initiatives that increase accuracy, productivity, and reimbursement efficiency
Requirements
- High school diploma or equivalent
- Demonstrated experience in medical billing, coding, insurance claims, or revenue cycle operations
- Working knowledge of ICD-10-CM, CPT, and HCPCS coding systems
- Understanding of commercial insurance, Medicare, Medicaid, and payer-specific claim requirements
- Experience with electronic health records (EHR), practice management software, and electronic claims platforms
- Knowledge of claim denial resolution, appeals, payment posting, and accounts receivable follow-up
- Strong analytical, organizational, communication, and problem-solving skills
- Ability to manage multiple priorities while maintaining accuracy and confidentiality
Nice to have:
- Postsecondary education in medical billing, coding, health information management, or healthcare administration
Important Details
Performance Expectations
- Coding and billing accuracy
- Clean claim submission rate
- Claim denial and rejection rates
- Timeliness of claim submission and follow-up
- Denial appeal success rate
- Accounts receivable aging and days outstanding
- Payment posting and reconciliation accuracy
- Productivity and quality assurance audit results
- Compliance with payer and regulatory requirements
Core Competencies
- Advanced attention to detail and analytical reasoning
- Strong knowledge of medical terminology and clinical documentation
- Effective claims investigation and denial resolution
- Excellent written and verbal communication
- Time management and workload prioritization
- Professional handling of confidential information
- Ability to work independently and collaborate across departments
- Commitment to continuous learning and regulatory compliance
Work Environment
- This position may be based in a hospital, physician's office, outpatient facility, specialty practice, or revenue cycle management organization. The specialist will work extensively with electronic medical records, billing systems, insurance portals, and claims management tools while meeting established quality, productivity, and turnaround-time expectations.