Billing Edits Representative - CPC

Job Summary:

The Claim Edit Reviewer (Clinical) must understand and comply with federal and state billing regulations. The Claim Edit Reviewer (Clinical) must ensure the confidentiality and privacy of information.

Essential Functions:

• Prepare and process accounts with edits in a timely and accurate manner.
• Review claim edits from electronic software; identify the edit and make appropriate corrections to ensure accurate claim resolution.
• Enter appropriate account notes into the billing system to clarify actions taken to reconcile claims.
• Review daily edit reports from work queues and/or in external billing software and make necessary corrections or resolve claim edits to allow electronic submission.
• Review and take appropriate actions to: a. Medical Necessity edits, b. Local Coverage Determination (LCD) and National Coverage Determination (NCD)edits, c. National Correct Coding Initiative (NCCI) edits, d. Modifier edits, e. Payer-specific edits, f. Medically Unlikely Edits (MUE), g. Procedure to Procedure (PTP) edits, h. Add-on edits, i. Medicare Outpatient Code Editor (OCE).
• Apply the correct modifier, remove, or determine non-billable charges that trigger an edit to resolve an edit based on Local Coverage Determination (LCD) edits, National Correct Coding Initiative (NCCI) edits, Modifier edits, Payer-specific edits, Medically Unlikely Edits (MUE), Procedure to Procedure (PTP) edits, Add-on edits, Medicare Outpatient Code Editor (OCE). Assure compliance with billing requirements for workers compensation and third-party liability claim.
• Maintains confidentiality of patient records at all times.
• Observes HIPAA compliance.
• Process re-bills as requested by collectors.
• Perform as a team player.
• Use logic, critical thinking and reasoning to identify the strengths and weaknesses of alternative solutions to problems.
• Understand the effects of new information for both current and future problem-solving and decision-making.
• High attention to detail
• Attendance in accordance with company HR and department policies
• Other tasks/functions that the company may assign as per business requirement; these may change from time to time to reflect the changing requirements of your position and our business.

Education/ Experience:

• Bachelor of Science in Nursing graduate or any Medical Allied Health course
• At least six (6) months of experience in an insurance, finance, medical, hospital, or customer service-related field.
• Preferably with work experience in a. Revenue Cycle (healthcare business, financial, or insurance) experience, b. Knowledge of medical and insurance terminology, ICD-10, CPT coding structures, c. Knowledge of billing forms (such as UB-04)
• Must be willing to work on a hybrid work set-up.