The Medical Billing & Coding Specialist is responsible for submitting accurate medical claims to insurance companies, ensuring timely reimbursement for healthcare services rendered. This role requires a deep understanding of medical coding, insurance policies, and billing regulations to avoid claim denials. The Medical Billing & Coding Specialist works closely with healthcare providers, RCM team members, and insurance companies to resolve discrepancies, clarify coding issues, and follow up on claims.

Core Job Duties & Responsibilities 

• Submit clean and accurate medical claims to insurance companies based on patient encounters and service documentation in a timely manner.
• Ensure that claims meet all insurance requirements to prevent delays or rejections.
• Review and resolve any issues identified by the claim scrubbers (front-end edits) before submitting claims to the payer.
• Identify errors such as incorrect codes, missing information, or inconsistencies, and correct them to ensure successful claim submission.
• Review coding for accuracy and ensure the correct use of CPT, ICD-10, and HCPCS codes.
• Identify and notify providers of any coding discrepancies, including missing or incorrect codes.
• Resolve coding-related issues by contacting providers for clarification or additional documentation when necessary.
• Serve as a resource and subject matter export to other team members.
• Notify healthcare providers of coding issues, incomplete claims, or missing information, and follow up until issues are resolved.
• Communicate clearly and professionally with providers to ensure that claims are correctly coded and resubmitted in a timely manner.
• Analyze and investigate denied or rejected claims to identify the root cause of the issue.
• Work with insurance companies and providers to resolve denied claims or appeal decisions where necessary.
• Maintain accurate and complete records of all claims, inquiries, and communications with providers and payers.
• Ensure compliance with all federal, state, and payer-specific billing regulations and guidelines.
• Other job duties as assigned.

Education/Experience:

• High school diploma or equivalent.
• 3 or more years of experience in medical billing, coding, or claims processing required.
• Experience working in healthcare organization with 50 or more providers in a multidisciplinary setting preferred
• Experience working in behavioral health strongly preferred
• Experience working with eCW or similar EMR/EHR system preferred

Licenses/Certifications:

• Certification in Medical Billing and Coding strongly preferred.

Knowledge, Skills, & Abilities

• Knowledge of HIPAA rules related to patient billing
• Knowledge of CPT, ICD-10, HCPCS coding, and insurance terminology
• Excellent verbal and written communication skills
• Ability to effectively and collaboratively communicate with peers, providers, and leadership to resolve questions
• Proficient with medical billing software and claim scrubber tools
• Highly organized and detail-oriented; strong attention to detail and accuracy
• Collaborative and team-oriented
• Flexible, adaptable, and able to move between tasks regularly
• Ability to troubleshoot and resolve billing issues efficiently
• Strong customer focus