Description
PURPOSE OF THIS POSITION
The Overlapping Coding Claims Specialist is responsible for the review, correction, consolidation, and support submission of claims involving overlapping encounters across multiple billing entities. This role ensures compliance with payer regulations regarding same-day services, 24-hour and 72-hour billing requirements, and medical necessity standards. The specialist will analyze encounters for medical relation, determine appropriate encounter combinations, move diagnoses and charges as needed, and support the submission of accurate claims for reimbursement.
JOB DUTIES/RESPONSIBILITIES
Duty 1: Identify encounters that meet 24-hour and 72-hour billing consolidation requirements. Review based on date of service, admission/discharge timing, entity, and payer-specific billing requirements. Identify "from" and "to" encounters when combining, moving, or consolidating services.
Duty 2: Evaluate medical records and billing documentation to determine whether encounters are medically related.
Duty 3: Move and/or combine diagnosis codes to ensure accurate claim representation and compliance with coding guidelines.
Duty 4: Review, combine, or transfer charges between encounters, as appropriate, based on payer regulations and organizational policies.
Duty 5: Consolidate claims when required to meet payer billing requirements. Provide support to billing team in releasing claims to insurance for payment.
Duty 6: Review and resolve claims issues through Quadax related to the 72/24 hour overlapping rules and medical relation.
Duty 7: Work collaboratively with coding, revenue integrity, patient access, PFS, and clinical departments to resolve billing issues.
Duty 8: Participates in daily huddles, idea board meetings, staff meetings, and meetings with external departments to manage daily improvements.
Duty 9: Communicate in a professional manner with patients, representatives from third party payor organizations, provider relations, contract management, other internal customers, and co-workers, etc. in a manner to achieve revenue cycle department AR goals.
Duty 10: Maintain current knowledge of Medicare, Medicaid, and commercial payer regulations related to overlapping encounters and bundled billing requirements.
- Duty 11: Ensures that services are provided in accordance with state and federal regulations, organization policy, and compliance requirements. Maintain compliance with HIPAA and institutional policies regarding patient information and financial data.
REQUIRED QUALIFICATIONS
High school diploma or GED equivalent
One (1)+ year of coding experience or completed education in medical coding/billing program.
Two (2)+ years of UB/facility billing experience. Strong knowledge of UB billing regulations and claim submission processes.
CPC, CCS, or CCA certification or obtained within the first 6 months of hire.
CPFSS certification within 12 months of hire.
Ability to analyze medical records and determine medical relation between encounters.
Demonstrated knowledge of medical terminology, anatomy, and physiology, including signs and symptoms, as it relates to healthcare billing, coding, and reimbursement processes.
Knowledge of revenue codes, CPT/APC/HCPCS, ICD/DRG coding, NCCI, HIPAA, and other applicable concepts. Knowledge of CMS 1500 forms, UB-04's, remittance advice, and itemized statements.
Knowledge of revenue cycle workflows and systems used within the Revenue Cycle such as Cerner, Trisus, Forvis, Quadax, KaiNexus, 3M, Experian, etc.
Regulatory compliance and reimbursement of methodologies knowledge required. Ability to research, review, analyze, and interpret Federal, State and Local billing regulations required.
Ability to compile, analyze and effectively present data and complex information in an informative and meaningful way to a variety of audiences, including leadership.
Ability to manage complex issues and manage multiple tasks/projects. Excellent organizational and time management skills; detail oriented and follow-through. Self-directed.
Strong problem-solving, research, and analytical skills.
Ability to effectively present and interact with all levels of the organization, including senior leadership
Positive service-oriented interpersonal and communication skills required.
PREFERRED QUALIFICATIONS
Associate's degree in a healthcare related field
Certified Professional Biller (CPB) certification.
PHYSICAL DEMANDS
This position requires a full range of body motion with intermittent walking, lifting, bending, squatting, kneeling, twisting and standing. The associate will be required to walk for up to one hour a day, sit continuously for six hours a day and stand for one hour a day. The individual must be able to lift twenty to fifty pounds and reach work above the shoulders. The individual must have good eye-hand coordination and fine finger dexterity for simple grasping tasks. The individual must have excellent verbal communication skills to perform daily tasks. The associate must have corrected vision and hearing in the normal range. The individual must be able to operate a motor vehicle for business travel and community involvement.
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