Medical Billing Specialist

The Ophthalmic Billing & E/M Coding Specialist is responsible for accurately posting clinic and hospital charges, with a primary focus on ophthalmology-related Evaluation & Management (E&M) coding. This role includes reviewing documentation from ophthalmologists, ensuring correct use of CPT and ICD-10 codes specific to ophthalmic services, drafting appeals for denied claims, assisting patients with understanding their accounts, and payment posting.

• Accounts Receivable (A/R):
  Monitor and follow up on aging reports to reduce outstanding, delinquent balances for both patients and insurance.
• Denial Management:
  Review and appeal denied rejected claims communicating directly with insurance payers.
• Verify coding accuracy by reviewing provider documentation against ophthalmology-specific coding guidelines, payer rules, and reference materials.
• Communicate with providers when documentation, dictation, or coding information is missing or unclear.
• Meet regularly with the Billing Supervisor to review and resolve coding questions, documentation issues, and payer-specific challenges.
• Draft well-supported appeal letters to insurance carriers for denials related to coding, documentation, or medical necessity, especially for ophthalmic services and diagnostic testing.

• Patient Inquiries:
  Resolve patient billing questions, manage account statements, and collect payments.
• Claims Submission:
  Electronically submit claims to insurance carriers, ensuring accurate coding for ophthalmology-specific procedures (e.g., cataract surgery, injections, OCT scans).
• Payment Posting:
  Accurately post payments from insurance (ERAs/EOBs) and patients to their respective accounts.

• Compliance:
  Ensure all billing activities adhere to HIPAA regulations and specific payer guidelines.
• Participate in staff meetings and continuing education, including ophthalmology-specific coding updates and compliance training.
• Promote clear and professional communication with clinical staff, providers, and coworkers.
• Aid coworkers and support team workflows as needed.
• Maintain a safe, organized, and clean work environment.
• Exhibit a professional and courteous appearance and demeanor appropriate for a patient-care setting.

To perform this role successfully, individuals must be able to perform each essential function satisfactorily. Reasonable accommodation may be provided for individuals with disabilities.

• Minimum of a high school diploma or equivalent.
• 2-5 years of medical billing experience, with preference for ophthalmology or surgical specialties.
• Proficiency in CPT, ICD-10, and modifiers, specifically regarding global surgery policies. Familiarity with surgical billing, global periods, and Medicare/Medicaid/Medi-Cal rules.
• Vast knowledge of Medical terminology.
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• Strong interpersonal skills, with the ability to communicate clearly and professionally with physicians and staff.
• Experience with EMR/billing systems such as Practice +, MoD MED, Tri Zetto, and Availity.
• Excellent organizational skills and a high level of accuracy, especially in reviewing documentation and entering charges.
• Strong attention to detail, analytical skills, and communication capabilities for handling patient and payer inquiries.
• Ability to read and create reports, checklists, and correspondence, and to understand complex written instructions. Excel knowledge a plus.
• Strong analytical skills with the ability to perform calculations and review detailed coding data quickly and accurately.
• Ability to apply common sense and sound judgment to resolve routine problems based on standardized procedures.
• Must be a self-motivated multi-tasker.
• Bi-Lingual is a plus