Professional Billing and Claim Specialist; Remote Job Worcester Massachusetts USA,Healthcare

Position: Professional Billing and Claim Specialist (Remote)

1. Prepare and submit HIPAA compliant claims to third- party payors through electronic data interchange (EDI) systems, clearinghouses, and payer specific submission platforms.

2. Review account documentation and billing records to ensure claim accuracy, completeness, and compliance with payer guidelines prior to submission.

3. Analyze billing edit reports, claim scrubber results, and payer rejection notifications; research, correct, and resubmit claims as appropriate and timely.

4. Collaborate with clinical, registration, coding and other departmental staff to resolve billing discrepancies and facilitate accurate claims submission in an automated billing environment.

5. Maintain working knowledge of CPT, HCPCS, ICD-10-CM, modifiers, occurrence codes, condition codes, span codes, and value codes applicable to assigned payer groups to support accurate claims processing and reimbursement. Update related billing information as directed by authorized clinical and administrative leadership.

6. Ensure all account corrections and adjustments are supported by appropriate documentation and departmental authorization for all account changes within Patient Accounting system.

7. Verify insurance information through eligibility verification, benefits, claim status utilizing payer portals, clearinghouse systems, and electronic sources such as WebMD, NEHEN, REV’s, FISS, and individual insurance carriers websites.

8. Research and resolve unbilled accounts, claim rejections, and claim edits through system reports, payer correspondence, online portals and other reports and/or claim listings where appropriate.

9. Investigate and resolve complex billing issues involving third party payors, government payers and federal/state agencies.

10. Process claim adjustments, corrections, cancelations, and manual claim submissions through payer websites and electronic billing systems as required.

11. Respond professionally and effectively to insurer inquiries in a timely, efficient and knowledgeable fashion, ensuring HIPAA guidelines are followed.

12. Utilize Microsoft Excel, Word, Outlook, Teams, and other healthcare information systems to create and maintain, analyze logs and reports as needed to support Patient Financial Services activities.

13. Performs related clerical activities including data entry, document management, filing, correspondence, and record maintenance.

14. Participates actively in departmental initiatives, process improvement efforts, and organizational projects supporting the revenue cycle performance.

15. Provide cross-coverage and support for departmental operations, including training activities and coverage during staff absences.

16. Complies with departmental and organizational policies including but not limited to, dress code, use of supplies, telephones and computers.

17. Adheres to work schedules and maintains a safe and orderly work area at all times, maintaining awareness of and compliance with safety policies and procedures.

18. Attends and participates in educational programs, in-service meetings, workshops, and other activities as related to job knowledge and state guidelines.

19. Analyze clearinghouse reports and automated billing system output to identify and resolve claim issues.

20. Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers.

21. Performs other related duties and assignments as requested.

Must read, write, and communicate in English
High School diploma or GED
(Preferred) Associate's or Bachelor's degree in Business, Healthcare Administration, or related field. Relevant healthcare experience may be considered in lieu of formal education
Minimum of one (1) year of experience in professional/physician medical billing, including electronic claim submission (EDI), clearinghouses, and payer portals
Working knowledge of:
- CPT, HCPCS, and ICD-10-CM coding conventions and modifiers
- Medical terminology
- Insurance billing guidelines
- Knowledge of HIPAA regulations
Proficiency with Microsoft Excel, Word, and Outlook
Strong analytical, organizational, and problem-solving skills, with exceptional attention to detail and the ability to manage multiple priorities in a fast-paced environment.
(Preferred) Experience using Epic or comparable electronic billing software