Position Summary:

　　Fulfills all requirements of an Insurance Billing Specialist II as well as identifies, analyzes and takes the necessary action to submit complex appeals to insurance payers. Reviews all medical chart and account documentation in order to determine appropriate coding and initiate corrected claims and appeals. Interprets payer guidelines, regulatory guidelines, contractual obligations and works with Department Management to ensure regulations/requirements are met. This position requires a thorough understanding of the requirements of the Government and Non‐Government payment policies & payer contracts. Trains Insurance Billing Specialists and related support staff, participates in billing projects and system testing as a Subject Matter Expert (SME). Works directly with Billing staff, Billing Supervisor/Manager/Director, Application Analyst and CRC departments when needed, to resolve complex issues and denials through independent research and assigned projects. This position works closely with a team of Denial Resolution Specialists to analyze and take corrective action on payer denials to ensure an optimum revenue cycle workflow.

　　Education, License & Cert:

　　High School Diploma or GED required. Associate degree preferred. CPC, CCA, RHIT, RHIA or certification in medical billing and coding is required. Certification requirement may be waived for years of experience and/or candidates actively pursuing certification.

　　Experience:

　　Minimum 3 years experience in insurance billing and/or coding. Must have proven experience in performing required tasks independently while contributing to the team environment. Strong organizational and customer services skills are a must. Previous experience in performing in a high volume and fast paced environment and demonstration of self‐motivation to develop and maintain the knowledge and skills for the position. Demonstrate ability to work independently and collaboratively.

　　Essential Functions:

　　Researches and analyzes denials on a daily basis, identifies root causes and processes resubmissions/appeals with the goal of overturning the denial and obtaining payment.

　　Responsible for assigned workqueues and resolves Charge Review, billing edits and follow up Denials by reviewing chart documentation, payer policies/guidelines/regulations and applying correct coding guidelines to ensure accurate and timely claim submission. Coding efforts include: CPT, ICD10, HCPCS, modifier and linkage.

　　Initiates complex appeal procedures and submits appeals for billing resolution by utilizing proficient coding skills. Works directly with payers when required. Utilizes rejection protocols, coding knowledge, reimbursement policies, payer guidelines and other sources to secure appropriate payment. Trends corrections and works with Reimbursement and provider office staff to educate.

　　Uses payer submission log and Follow up Workqueues to identify and/or troubleshoot payment delays. Works directly with payer through resolution.

　　Demonstrates skills and proficiency in analyzing and troubleshooting complex billing problems. Interprets payer guidelines, bulletins and website communications for billing guideline changes and compares to internal logic. Follows up appropriately with discrepancies and works with department management and IT for logic and process updates.

　　Monitors assigned payers days in Accounts Receivables (AR), analyzes work queues and other system reports for trends and/or contract noncompliance. Reports to Billing Supervisor/Manager/Director.

　　Performs testing and monitoring of new system logic or processes and provides feedback to ensure accurate and timely clean claim submissions.

　　Other Duties:

　　Utilizes Epic system functions accurately to perform assigned tasks. Example: charge corrections, charge entry, invoice inquiry, credits, payment distribution, workqueues, EHR, etc. Trains and supports other staff as requested. Cross trains in all billing processes and Epic modules

　　Works with payers to follow up on claims resubmitted via the payer appeal process.

　　Responsible for timely filing and appropriate follow up of secondary insurance billings, analyzing EDI submissions for accuracy and coordination of benefits.

　　Responsible for timely resolution of credit balance as assigned. Identifies project opportunities and works with payers and assigned Insurance Billing Specialists to resolve credit balances.

　　Provides feedback related to workflow processes in order to promote efficiency.

　　Request adjustments on invoices that have been thoroughly researched and/or were unable to reach payment resolution. Documents support on request forms.

　　Answers phone calls and correspondence providing request information for appropriate follow up.

　　Maintain knowledge and performs within the compliance of clinic policies and payer regulations/guidelines.

　　Assists in creation and/or revision of departmental policies and protocols.

　　Demonstrates excellent customer services skills for both internal and external customers.

　　Aids in training of other employees.

　　Assists with and completes projects and other duties as assigned.

　　Joining the Guthrie team allows you to become a part of a tradition of excellence in health care. In all areas and at all levels of Guthrie, you’ll find staff members who have committed themselves to serving the community.

　　The Guthrie Clinic is an Equal Opportunity Employer that welcomes and encourages diversity in the workplace.

　　The Guthrie Clinic is a non-profit, integrated, practicing physician-led organization in the Twin Tiers of New York and Pennsylvania. Our multi-specialty group practice of more than 500 physicians and 302 advanced practice providers offers 47 specialties through a regional office network providing primary and specialty care in 22 communities. Guthrie Medical Education Programs include General Surgery, Internal Medicine, Emergency Medicine, Family Medicine, Anesthesiology and Orthopedic Surgery Residency, as well as Cardiovascular, Gastroenterology and Pulmonary Critical Care Fellowship programs. Guthrie is also a clinical campus for the Geisinger Commonwealth School of Medicine.