Medical Coder & Billing Specialist

Job description

**POSITION SUMMARY** This position will be responsible for performing on-going auditing of outpatient provider coding, and education. Individuals must be a certified coder, with experience in NY Medicaid regulations. The Senior Coding & Billing Specialist is responsible for auditing outpatient provider coding and documentation to ensure accurate code assignment, regulatory compliance, and optimal reimbursement. This position serves as a subject matter expert in CPT, ICD-10-CM, HCPCS, New York State Medicaid, CMS, and commercial payer requirements, ensuring services are coded and billed accurately in accordance with applicable federal, state, and payer guidelines. In addition to coding audits, this role is responsible for reviewing and resolving billing work queues, analyzing claim denials and reimbursement trends, identifying charge capture and documentation opportunities, and supporting timely claim resolution. The Senior Coding & Billing Specialist partners with providers, operations, finance, and revenue cycle leadership to improve documentation quality, reduce denials, optimize reimbursement, and strengthen overall revenue integrity through education, Epic optimization, auditing, and continuous process improvement. **DUTIES AND RESPONSIBILITIES** **Revenue Cycle Coding Functions (45%)** - Identify provider documentation improvement opportunities through coding audits and collaborate with providers and clinical leadership to enhance documentation quality and optimize reimbursement. - Identify coding, billing, charge capture, and documentation issues impacting reimbursement and provide recommendations for corrective actions to the VP of Revenue Cycle. - Identify coding-related payer denials and collaborate with appropriate stakeholders to reduce denials and improve coding accuracy. - Maintain current knowledge of CPT, ICD-10-CM, HCPCS, CMS, New York State Medicaid, and commercial payer coding requirements and educate providers and staff in regulatory updates. - Analyze trends in provider documentation, coding accuracy, and missed coding opportunities, and develop professional educational materials and recommendations for providers. - Collaborate with third-party revenue cycle vendors to identify coding issues and opportunities and develop remediation plans. - Recommend Epic automation, SmartSets, documentation templates, hard stops, soft stops, and workflow enhancements to improve coding accuracy, documentation compliance, and reimbursement. - Perform other duties and special projects as assigned. **Revenue Cycle Billing (40%)** - Work assigned Epic billing work queues (WQs) to timely resolution, ensuring accurate claim submission and reimbursement. - Identify Epic billing work queue issues and collaborate with Revenue Cycle leadership to develop and implement corrective action plans and workflow improvements. - Identify billing edits, charge capture, pricing discrepancies, claim rejections, and reimbursement issues, and recommend corrective actions to optimize revenue. - Perform billing and reimbursement audits utilizing EpicSlicerDicer and various other reporting tools, and advanced Microsoft Excel functions, including Pivot Tables to ensure compliant billing and accurate reimbursement. - Maintain current knowledge of New York State Medicaid, CMS, and commercial payer billing regulations, reimbursement methodologies, and payer contract requirements, and communicate updates to appropriate stakeholders. - Monitor billing work queues, denial trends, and timely filing requirements to improve first-pass claim acceptance and reduce revenue leakage. - Collaborate with the VP of Revenue Cycle Operations and Optimization to resolve complex billing and reimbursement issues. - Identify opportunities for Epic billing automation, workflow optimization, and process improvement to enhance operational efficiency and reimbursement. - Participate in revenue cycle initiatives, system testing, and special projects as assigned. **Training and Education (15%)** - Develop and provide ongoing education for current and new providers regarding coding accuracy, documentation requirements, reimbursement, and regulatory compliance. - Evaluate the results of internal and external coding audits and partner with Revenue Cycle, Operations, and Clinical Leadership to provide education, feedback, and corrective action plans to improve provider coding performance and documentation quality. - Maintain current knowledge of CMS, New York State Medicaid, and commercial payer coding and billing regulations, and communicate updates to providers and Revenue Cycle staff. - Complete all required organizational training and participate in departmental meetings, educational sessions, and revenue cycle initiatives. **CORE COMPETENCIES** - A demonstrated commitment to PPGNY’s mission related to bodily autonomy, health equity, gender and racial justice. - A demonstrated commitment to learning about and enhancing practices related to racial equity and its impact on healthcare systems. - Strong relationship building skills, including an ability to work and build trust across cultural differences related to race, age, gender, gender identity and expression, sexual orientation, religion, ethnicity, national origin or ability; and to reflect on one’s personal identity with humility. - Customer service and interpersonal skills and the ability to coordinate work with others, both internally and externally, engages in mutual problem solving. **REQUIRED SKILLS/ABILITIES** - Knowledge of Third-party payer contracts and Medicaid reimbursement - CPT4 ICD-10 coding requirements and compliance and all other carrier guidelines; strong knowledge of New York State Medicaid rules. - Ability to learn data and analytics techniques to ensure good decision making, performance measurement and financial analysis. - Strong time management skills, including the ability to work in a high distraction environment and to juggle multiple deliverables at one time. - Excellent interpersonal, written and verbal skills and the ability to explain complex coding regulations to individuals who are not subject matter experts. - Strong team building skills. - Proficient with Microsoft Office Suite, including Excel skills, such as macros, pivot table and v look up options. - Demonstrated ability to learn new systems. - Process improvement orientation. - Proven ability to remain focused and calm in stressful situations. **REQUIRED QUALIFICATIONS** **Minimum Education and Work Experience** - High school diploma/GED. - Five plus years’ experience in outpatient provider coding, including coder certification. - Five plus years’ experience in compliant provider documentation. - Three plus years’ experience in EPIC EMR coding, billing and provider documentation. - Strong knowledge and utilization of Microsoft Windows, Excel, Word, Power Point and Outlook. - Strong CMS Compliance knowledge and audit guidelines. **PREFERED QUALIFICATIONS** - Associate’s degree in business. **TYPICAL PHYSICAL DEMANDS** Requires prolonged sitting and repetitive tasks including use of a computer. Periodic standing, walking, bending. Requires lifting or moving of up to 15 pounds. Visual acuity sufficient to perform frequent work on a computer screen and review printed reports and other materials. Requires the ability to hear and to communicate orally with others. This role routinely uses standard office equipment such as computers, phones, photocopiers, and filing cabinets, and will require reaching, grasping, pushing, and pulling. **TYPICAL WORKING CONDITIONS** This job operates in a professional office environment. Potential exposure tocommunicable diseases and other conditions in a health center environment. Requiresflexible schedule and during peak activity periods work more than 7.5 hours per dayand/or 37.5 hours per week.