Billing and Coding Specialist (FT)

Job Title

Reviews waiver budget variances by actively monitoring and completing financial analysis for anchor budget and addendum purchasing submission. Reviews coding and billing practices at United Summit Center to ensure consistency and compliance across the organization. Communicates with clinical staff to address holds, anchor dates and large budget variances accurately and timely. Effectively monitors and tracks issues and concerns to develop process improvement opportunities. Effectively monitors and tracks ever-changing coding practices and develops process improvement opportunities. Trainings and advises staff on coding processes and information. Acts as liaison between Billing Department and IT.

Minimum Qualifications:

1. High school graduate or equivalent.

2. State criminal background check and Federal (if applicable), as required for regulated areas.

Experience:

1. One (1) year of medical billing experience.

Preferred Qualifications:

1. Waiver billing experience.

2. System billing experience.

3. Finance experience.

Core Duties and Responsibilities: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Provide data insights for the purpose of Waiver budget creation, update and maintain waiver budget reconciliation tool, and create pivot tables for IDD waiver budget review.

2. Monitor team Dashboard update and manage team SharePoint.

3. Filter Tickets in billing system prior to sending the information to IT.

4. Conduct billing system configuration insight and repair by partnering with IT and create workflow instructions for billing system.

5. Monitor monthly waiver billings against projected monthly budgets to assure current residential schedules agree to actual billings and partners with case managers to resolve issues.

6. Perform random audit functions (billing vs payroll) for non-24 hours client members.

7. Identify all patients requiring pre-certification or pre-authorization at the time services are requested or when notified by another hospital or clinic department.

8. Follow up on accounts as indicated by system flags.

9. Contact insurance company or employer to determine eligibility and benefits for requested services.

10. Follow up with the patient insurance company or provider if there are insurance coverage issues in order to obtain financial resolution.

11. Use work queues within the designated EMR or appropriate system for scheduling, transition or care, and billing edits.

12. Perform medical necessity screening as required by third party payors.

13. Document referrals/authorizations/certification numbers in the designated EMR.

14. Communicate with the patient the anticipated self-pay portion co-payments/deductibles/co-insurance, and account balance refers self-pay, patients with limited or exhausted benefits to the in-house Financial Counselors to determine eligibility.

15. Maintain current knowledge or major payor payment provisions and regulations and participate in educational programs to meet mandatory requirements and identified needs with regard to the job.

16. Assist Patient Financial Services with denial management issues and will appeal denials based on medical necessity as needed.

17. Analyze patient charts carefully to know the diagnosis and represent every item with specific codes.

18. Collect health information as documented by clinicians and code appropriately.

19. Communicate with clinicians for further clarification and understanding of items on patient charts to avoid any misinterpretations.

20. Ensure that codes tally with clinicians' diagnosis.

21. Advocate for patients where their medical history is needed as evidence.

22. Collect and distribute coding related information and billing issues to UM, Billing department, and Clinicians.

Physical Requirements: 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.

1. Prolonged periods of sitting required.

2. Extended periods on the telephone requiring clarity of hearing and speaking.

3. Must have manual dexterity to operate keyboards. Fax machines telephones and other business equipment.

Working 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.

1. Outpatient clinical environment.

Skills and Abilities:

1. Excellent oral and written communications skills.

2. Basic knowledge of medical terminology.

3. Ability to accurately utilize applicable computer software and equipment for access processing.

4. Basic knowledge of third party payors.

5. General knowledge of time of service collection procedures.

6. Excellent customer service and telephone etiquette.

Additional Job Description:

Scheduled Weekly Hours: 40

Shift:

Exempt/Non-Exempt: United States of America (Non-Exempt)

Company: WH Wheeling Hospital Inc.

Cost Center: 72 WH Nursing Operating Room

Address: 1 Medical Park Drive Wheeling West Virginia

Equal Opportunity Employer

West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.