Clinical Billing Specialist

Purpose:

Do you have nursing experience as an RN or LPN? Do you have healthcare billing and denial experience? UPMC is hiring a full-time Clinical Billing Specialist to support the Care Management department. This position would work Monday through Friday during daylight hours. The position is eligible to work from home.

The Clinical Billing Specialist serves as a clinical resource person for all Patient Business Services areas. They conduct charge audits and participate in the development of new programs. The Billing Specialist also supports patient inquiries that require a clinical review of their bill, as well as development of CQI initiatives within the PBS area.

If this sounds like the job for you, apply today!

Responsibilities:

• Appeal payer denials as requested.
• Coordinate payor audits, conduct post audit to validate auditor findings and identify unbilled for services, and negotiate agreement with the payor regarding final outcomes.
• Keep management informed of the status of all assignments.
• Ability to communicate and work with physicians, physician office personnel, associates, care managers, third party payer review personnel, and others in order to expedite the billing and accounts receivable process.
• Assist in monitoring, reporting and developing process improvement initiatives to ensure regulatory compliance.
• Perform CDM maintenance tasks in a timely manner.
• Maintain contact with ancillary department managers to use as a resource to obtain information on price estimates and to resolve any charge issues/problems.
• Retrieve, review and release medical records in accordance with the defined functional area.
• Assist the clinical staff in bringing about payor policy change associated with new and/or innovative approach to care.
• Assist with the development of CQI initiatives within the PBS areas.
• Maintain department productivity levels.
• Assist in clearing claims for billing as indicated.
• Assist the Patient Business Services department and other UPMC areas in responding to billing inquiries/complaints, which require a clinical understanding.
• Ability to interpret third party payor contract requirements and recommend, design and implement procedures for compliance with regulations and standards.
• Adhere to the UPMC and Patient Business Services Standards of Conduct.
• Understanding of utilization management as it relates to the continuum of care.
• Ability to compare clinical findings with payor requirements, educate physicians regarding requirements and obtain supporting documentation from the physician or local policies that substantiate medical appropriateness as indicated.
• Maintain department productivity levels.
• Adhere to departmental policies and procedures.
• 5 years of varied nursing experience, and a minimum of 3 years of experience in a health care financial environment preferred.
• B.S. degree in a health care related field or Business Administration is preferred.
• 2-5 years patient account experience preferred.
• Familiarity with the Medipac system and PC work processing, spreadsheet and data base software is preferred.
• Knowledge of CPT-4 and revenue coding is strongly preferred.
• Knowledge of SI/IS criteria for commercial, Medicare, and Medicaid insurance products in order to substantiate use of resources and compliance with third party contracts.

Licensure, Certifications, and Clearances:

• Act 34

UPMC is an Equal Opportunity Employer/Disability/Veteran