Summary

Position responsibilities may include but not limited to medical coding and billing, credentialing of professional providers and facilities, and accounts receivable claim account resolution. Account resolution includes all balances, debit or credit, for all assigned payors including patient balances. Understands complex patient, commercial and government funded billing structure in order to effectively perform job duties. Ability to audit and provide coding education and feedback to providers and operations leadership. Maintains a positive outlook and flexibility to effectively work in a team environment performing various assigned tasks accurately and with deadlines. Understands the importance and relevance of assigned tasks in meeting overall department goals and requirements.

Essential Functions

• Medical Coding responsibilities:
  • Comply with all legal requirements regarding coding procedures and practices
  • Conduct audits and coding reviews to ensure all documentation is accurate and precise
  • Assign and sequence all codes for services rendered
  • Contact physicians and other health care professionals with questions about treatment or diagnostic tests given to patients with regard to coding procedures
  • Provide education and feedback to providers, including annual E/M coding guidelines and annual external coding audits
• Assist and backup of Credentialing of medical providers:
  • Compile and maintain current and accurate electronic data for all providers
  • Create, update and maintain CAQH Proview data base accounts for PPGC/PPCfC clinicians, physician assistants, and physicians. Acquire accounts for new providers (APRNs, PAs, and Physicians) not previously registered with CAQH
  • Provide all payers with Demographic updates when providers are added or terminated
  • Complete and maintain the Affiliate Risk Management Services (ARMS) required credentialing and re-credentialing of all PPGC and ASC providers (RNs, APRNs, PAs, & MDs) with third party primary source verification (PSV) service
  • Maintain and monitor all facility credentialing and providers professional licensing
• Performs electronic billing process as scheduled and follow up on claims rejection in Clearing House
• Makes correction and prepares appeals related to claim denials as necessary
• Posts patient, Medicaid, MCO, and commercial payer payments, recoupments, and adjustments with a high attention to detail, timeliness, and accuracy
• Identifies tracks, analyzes, and reports unusual denial or non-payment trends and discusses with supervisor
• Maintains open, ongoing communication with Centralized (CHN) and PPGC staff (i.e. Contact Center, Health Center Managers and staff) answering questions and providing guidance as necessary
• Understands the state Medicaid Manuals and the terms of the Medicaid, MCO, and Commercial payer contracts in order to troubleshoot claim information and ensure data is accurate
• Works AR Aging process, as directed by the supervisor
• Analyzes AR Aging reports and reviews and researches unpaid claims for collectability, correcting or refiling claims accordingly
• Identifies issues and discusses with Supervisor as they occur
• Assist with Revenue Projections prepared from information obtained from electronic billing system

General Duties

• Maintains general working knowledge of the business and operations in order to effectively perform job duties, provide customer service and detect and resolve issues
• Maintains accurate, organized and logical filing system for all documents
• Communicates with insurance companies about billing / coding errors and disputes
• Understands the importance and relevance of assigned tasks in meeting overall departmental and organizational goals and requirements
• Works closely with the Revenue Cycle Manager and staff to coordinate payment postings, appeals, tracking denied claims, and any other projects or duties as necessary
• Under the direction of departmental management:
  • Assists with Annual year-end audit preparation as requested
  • Assists with month-end close process as requested
• Understands data gathering and reporting capabilities of our systems (i.e. Epic, Experian, Share Point, Excel, and various payer websites) in order to efficiently problem-solve by generating reports and extracting data with minimum direction
• Effectively utilizes technology to gather report and analyze data as appropriate
• Maintains open communication with Fiscal team
• Must have the ability to work accurately within operational deadlines
• Ability to shift priorities based on changing needs
• Participates in team meetings by providing project updates, status, and completion information
• Helps maintain all policy and procedural documentation related to assigned duties to ensure documentation is current, complete and accurate
• Actively participates in the continuous improvement of policies, procedures and controls
• Performs special projects or other duties, as assigned, in a timely and accurate manner

Supervisory Responsibilities

This job has no supervisory responsibilities

Competencies

To perform the job successfully, an individual should demonstrate the following competencies:

• Core Competencies: Computer skills, Mathematical Aptitude, Customer Service, Dependability, Diversity, Ethics, Initiative, Interpersonal Skills, Oral Communication, Organizational Support, Professionalism, Quality, Safety & Security, Teamwork, Written Communications and exposure to Medical Terminology.
• Analytical, Business Acumen, Delegation, Decision Making, Innovation, Judgment, Managing People, Planning/Organizing, Problem Solving, Project Management, Quantity, Technical Skills
• Attendance and Punctuality

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and / or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

• Must have strong interpersonal and communication skills: both verbal and written; and ability to relate persons of diverse backgrounds
• Ability to handle highly confidential and sensitive matters and documents
• Ability to define problems, collect data, establish facts and draw valid conclusions
• Ability to interpret and extensive variety of technical instruction in mathematical or diagram form and deal with several abstract and concrete variables
• Ability to priorities and handle multiple projects
• Ability to demonstrate initiative and to work with minimal direction
• Ability to perform duties in a manner that exhibits commitment to providing quality service and continuous improvement

• Strong General Technology Skills; proficient utilization of Excel, Word, and Windows environment, Epic or other practice management systems experience a plus
• Excellent typing and 10-key speed and accuracy

Education and/or Experience

• CPC Certification is required
• Bachelors Degree preferred
• Minimum of 2 years direct experience with Medical Coding
• Minimum of 2 years direct experience with Credentialing providers in a medical practice, with the accompanying knowledge and understanding of the credentialing process with health insurance plans and use of CAQH Proview

Language Skills

• Ability to read, analyze, articulate and interpret general business periodicals, common scientific and technical journals, or government regulations.
• Ability to read, analyze, articulate and interpret common medical and health plan journals, financial reports, and legal documents, inclusive of Remittance and Status documents
• Ability to write reports, business correspondence, and procedure manuals
• Ability to effectively present information and respond to common inquiries or complaints from customers, regulatory agencies, and members of the business or medical community

Mathematical Skills

• Ability to work with mathematical concepts such as probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry, in addition possessing basic math skills.
• Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.

Reasoning Ability

• Ability to define problems, collect data, establish facts, and draw valid conclusions.
• Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.

Computer Skills

• Must have highly advanced computer skills, especially in the use of the following software: Microsoft 2010 (Excel, Word, and One Note) or higher, CAQH
• Adobe Acrobat Professional XI or higher (must be able to create and edit fillable forms in Adobe Acrobat)
• Epic or other practice management system experience a plus.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit, talk, and hear. The employee is frequently required to use hands to finger, handle, or feel. The employee is occasionally required to stand; walk; reach with hands and arms; climb or balance; stoop, kneel, crouch, or crawl and taste or smell. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, and ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is occasionally exposed to outside weather conditions. The noise level in the work environment is usually moderate.

Planned Parenthood is an equal opportunity employer. We are dedicated to ensuring that all of

our decisions regarding all aspects of the employment relationship including recruiting, hiring,

promotions, assignment, training, access to social and recreational programs, discharge,

compensation, benefits, and the terms, conditions, and privileges of employment are in

accordance with our principles of equal opportunity. It is Planned Parenthoods policy that, in

exercising our management responsibilities, we will not discriminate against teammates or

applicants on the basis of race, color, national origin, ethnicity, religion, age, sex, gender, marital

status, sexual orientation, gender identity, gender expression, genetic information, military

service, covered veteran status, physical or mental disability, pregnancy, childbirth, or related

medical conditions, political opinions or affiliations, or on the basis of any other status protected

by applicable federal, state, and/or local law. It is our objective to hire and promote individuals

who are qualified for positions by virtue of job-related considerations such as education,

knowledge, skills, training, and experience.