Claim Readiness Specialist

The Claim Readiness Specialist is responsible for entering and importing charges and ensuring the appropriate billing codes on used for all charges. The Claim Readiness Specialist will ensure charges are entered accurately, efficiently, and timely into the practice management system. The Claim Readiness Specialist is also responsible for resolving all assigned claim edits and submission of claims to third party payers within the clearinghouse/practice management system in a timely and efficient manner. They work with Coding and Revenue Integrity Supervisor to escalate charge entry and bill submission issues to prevent incorrect billing. This role reports to the Revenue Integrity Supervisor.

ESSENTIAL JOB FUNCTION/COMPETENCIES

• Enters and import charges daily for all professionals ensuring accurate coding
• Determines correct CPT codes for professional surgical procedures along with Evaluation and Management (E&M) clinical encounters. Also determines appropriate all ICD-10 diagnosis codes
• Ensures all prior day’s charges and edits have been accurately resolved and claim is ready to bill insurance in a timely manner.
• Identifies root cause issues causing charge edits and communicates these issues to leadership for upstream education
• Communicates with Coders, Business Office staff and Providers when necessary to resolve errors and clarify issues
• Stays accountable to quality and productivity standards, and monitor compliance with policies and procedures
• Identifies process opportunity trends and recommend ways to improve efficiencies
• Ensures adherence to third party and governmental regulations relating to coding, billing, documentation, compliance, and reimbursement
• Participates in special projects, personal development training, and cross training as instructed
• Informs Supervisor, Coding and Revenue Integrity of trends, inconsistencies, discrepancies for immediate resolution
• Works in conjunction with peers and functional areas of the Coding and Revenue Integrity department for the betterment of completing tasks and the company overall
• Job may require other duties as assigned.

CERTIFICATIONS, LICENSURES OR REGISTRY REQUIREMENTS

• Certified Professional Coder (CPC) preferred.

KNOWLEDGE | SKILLS | ABILITIES

• Demonstrates and uses a strong working knowledge of CPT coding and ICD10 coding as it relates to urology services.
• Understands the utilization of modifiers and other billing and coding rules to include the AMA and other billing and coding organizations.
• Knowledge of medical terminology and consistent application of medical documentation requirements.
• Minimum 2 years hands on coding and/or billing experience within a physician’s office and/or successful completion of secondary education in medical coding/billing or medical administration, or urology experience
• Ability to follow policies and procedures for compliance, medical billing, and coding.
• Ability to type and enter data with proficiency and accuracy
• Proven ability to manage multiple projects at a time while paying strict attention to detail
• Ability to successfully meet established timelines
• Ability to operate essential office equipment, including multi-line phone, computer, fax machine, scanner, and photocopy machine.

EDUCATION REQUIREMENTS

• High school diploma or general education degree (GED); or equivalent combination of education and experience.

EXPERIENCE REQUIREMENTS

• Minimum of three years’ revenue cycle experience within a physician practice
• Experience in Urology or physician practice environment preferred