The Medical Coding and Billing Specialist is responsible for writing and maintaining coding and billing rules in the practice management system. The position is also responsible for reviewing and importing daily charges in Radiology Authorization Specialist and daily claim filing. Excellent verbal and written communication skills required. The coding and billing works under the direct supervision of their respective team manager.

Responsibilities:

• Review and verify patient insurance coverage and eligibility for proton therapy treatments.

• Verify all applicable charges for proton therapy, radiation therapy, and radiology services are entered timely and accurately into the practice management system for reimbursement.

• Generate and submit accurate and timely claims for proton therapy, radiation therapy, and radiology services to insurance payers.

• Monitor and track claims through the billing process to ensure timely payment and identification of payer roadblocks.

• Assist with investigation and resolution of any claim rejections, denials, or appeals related to proton therapy treatments.

• Review and interpret insurance policies and regulations related to proton therapy treatments to ensure compliance with billing requirements.

• Work collaboratively with the proton therapy center's medical and pre-authorization teams to ensure accurate and complete billing for proton therapy and radiation therapy treatments

• Maintain accurate and up-to-date records of billing activities in patient files and computer systems

• Ability to review and interpret radiation oncology medical records for accuracy as it relates to coding and billing. Educate clinical team on appropriate documentation requirements.

• Assist team members with responses to patient and insurance company inquiries about billing for proton therapy treatments in a timely and professional manner

• Stay current with industry trends, changes to insurance policies, and other developments that may impact the billing process for proton therapy and radiation therapy treatments.

• Review and verify patient insurance coverage and eligibility for proton therapy treatments as needed.

• Reviews charges in “Approve Failed” status daily for accuracy and corrective action.

• Contacts the appropriate department to follow up on pending issues for insurance and referrals.

• Works Research ACE tasks in Unity daily.

• Reviews charges on “Hold” status daily for accuracy and corrective action.

• Creates new Ace rules/edits as needed to reduce claim denials and/or manual review.

• Maintains Ace rules to ensure data is current.

• Runs Ace edits daily and files paper and electronic claims to the appropriate payors.

• Keeps informed regarding current coding regulations, auditing, professional standards and company/department policies and procedures as it applies to the field of medical oncology and effectively applies this knowledge.

• Communicates effectively with practice leadership regarding coding issues to help ensure coding compliance and minimize denials.

• Demonstrates outstanding work ethic and works cooperatively with all team members and management.

• Additional responsibilities may be assigned to help drive our mission of improving the lives of everyone living with cancer.

Required Qualifications:

EDUCATION & EXPERIENCE:

• Bachelors degree preferred

• Minimum two years’ experience in charge entry/billing required.

• 1+ year(s) of Prior Authorization experience.

• Extensive knowledge of CPT, HCPCS, and ICD-9 coding in addition to insurance billing guidelines required.

• Proficiency in Microsoft EXCEL spreadsheets and strong computer background.

• Medical insurance background required.

• Expertise in insurance policies and regulations related to medical billing, including Medicare and Medicaid

Essential Competencies:

• Attendance is an essential job function.

• Ability to work effectively with all levels of management and other colleagues

• Ability to demonstrate initiative and mature judgment.

• Ability to demonstrate high degree of professionalism and adaptability.

• Ability to demonstrate proficiency in the use of end-user computer applications (MS work, Excel, Outlook), database and patient scheduling and other medical information systems.

• Ability to demonstrate strong customer service delivery skills.

• Ability to utilize websites, portal and electronic options when available to increase efficiency

• Ability to follow oral and written instructions.

• Ability to recognize and solve problems using creative thinking skills, hands on problem solving skills and the ability to analyze and respond to data.

• Skilled at effective verbal and written communications, including active listening skills and skill in presenting findings and recommendations.

• Skilled at Multi-tasking, organizational skills and superb attention to detail.

• Working knowledge of Hospice and other payer requirements.

• Knowledge of clinic office procedures, medical practice and medical terminology.