Position Summary:
The Medical Billing and Coding Specialist is responsible for accurately processing, reviewing, and submitting medical claims for a large multi-specialty physician practice. The role ensures timely reimbursement by verifying coding accuracy, resolving claim edits, following up on outstanding balances, and supporting patients and providers with billing inquiries. The Specialist collaborates closely with outsourced billing company employees, clinical departments, and payers to uphold revenue integrity and optimize financial performance.
Qualifications: Education, Licensure and Certifications, Related Work Experience:
- High school diploma or equivalent.
- Minimum 10 years of medical billing experience, preferably in a multi‑specialty or large physician practice setting.
- Certification as a Certified Professional Coder (CPC) or similar credential is required
Other specialized skills and knowledge necessary to perform this job. (e.g., basic accounting principles, computer skills and software, specific healthcare processes, interpersonal, communication, etc.
- Strong understanding of CPT, ICD‑10, and HCPCS coding principles.
- Familiarity with Medicare, Medicaid, and major insurance plans
- Proficiency with EMR and practice management system
- Strong attention to detail and ability to manage multiple tasks in a high‑volume environment
Essential Job Duties/Responsibilities
- Review and correct coding denials from outsourced billing company for resubmission to insurance carriers, government programs, and third‑party payers per payer guidelines
- Review charges for accuracy, completeness, and compliance with CPT, HCPCS, and ICD‑10 coding standards
- Resolve claim edits, denials, and rejections by correcting coding errors and/or assisting providers with coding corrections
- Conduct timely follow‑up on unpaid or underpaid claims to ensure optimal reimbursement
- Process adjustments, refunds, and billing corrections as needed
- Respond to patient billing inquiries professionally and with strong customer service
- Monitor aging reports and maintain accounts receivable within departmental benchmarks
- Collaborate with billing teams and clinical teams to clarify documentation or coding discrepancies
- Maintain knowledge of payer policies, contract terms, and regulatory billing guidelines
- Support month‑end close processes and assist with revenue cycle projects as assigned
- Other related duties as assigned.
Compliance Requirements
Adherence to Laws, Rules, Regulations, Standards, Guidelines, Policies and Procedures:
- Ensure compliance with all federal, state, and local laws, regulations, standards, guidelines, and Eventus WholeHealth policies and procedures pertaining to the job.
- Remain informed of any changes to federal, state, and local laws, regulations, standards,guidelines, and Eventus WholeHealth policies and procedures that impact the job and the company.
- Promptly report any non-compliant conduct and/or practices to Eventus WholeHealth’s Chief Compliance and Risk Officer.
Ethical Conduct:
- Ensure adherence to Eventus WholeHealth's Code of Ethics and Business Conduct.
- Perform the job duties with integrity and professionalism.
- Promptly report any unethical conduct and/or practices to Eventus WholeHealth’s Chief Compliance and Risk Officer.
Patient Privacy and Confidentiality:
- Strictly protect patient information in accordance with all federal and state privacy laws and Eventus WholeHealth policies and procedures.
- Promptly report any violations of federal and state privacy laws and Eventus WholeHealth
- policies and procedures to Eventus WholeHealth’s Chief Compliance and Risk Officer.
Documentation and Record Keeping:
- Maintain accurate and complete documentation when performing the job duties.
- Ensure that all Eventus WholeHealth information, data, documentation, and records are always safeguarded and maintained confidentially.
Training and Education:
- Participate in all assigned training.
- Complete all assigned training by the deadline for completion.
Risk Management and Incident Reporting:
- Engage in regular risk assessments to identify potential risks and work proactively with a supervisor and Eventus WholeHealth’s Chief Compliance and Risk Officer to mitigate any identified risks.
- Promptly report any incidents (as defined in the “Incident Report Policy”) to the Chief Compliance and Risk Officer.