JOB DESCRIPTION

The Procedural Billing Specialist III is a senior level individual, responsible for multiple components of the billing process for specialized or complex pre and post-surgical procedures, including coding, Accounts Receivable, Charge Entry, Edits and Payment Posting. Facilitates claims processing for services rendered by physicians. Assists with responses to problems or questions on benefit eligibility and reimbursement procedures. Independently engages or participates in the negotiation process with third party carrier Medical Directors and other representatives. Coordinates activities related to data entry of billing; performs staff training. Demonstrates proficiency in analysis and problem resolution to ensure accurate and timely payment of claims and collection. Maintains open dialogue with the Department Administrator or Manager on billing activity and current concerns.

RESPONSIBILITIES

• Performs specialized coding services for complex or more specialized inpatient and outpatient medical office visits. Reviews physician coding and provides updates.

• May provide financial counseling to patients, discussing the details concerning their insurance coverage and financial implications of out-of-network benefits, including pre-determination of benefits, appeals and/or pre-certification limitations. Develops and manages fee schedules and for self-pay patients.

• Identifies submitted and required documentation to maximize revenue capture.

• Processes Workers Compensation claims and addresses/resolves all discrepancies.

• Conducts specialized negotiations with insurance companies, including engagement with Medical Directors and other relevant parties. Establishes a network of key representatives within the insurance pre-certification units to establish open lines of communication for future service negotiation.

• Manages or participates in the appeals process for claims as required.

• Verifies insurance and registration data for scheduled office, outpatient, and inpatient procedures. Reviews encounter forms for accuracy. Responsible for obtaining pre-certifications for scheduled admissions.

• Enters or oversees the accurate entry of office, inpatient, and/or outpatient charges. Runs and works missing charges, edits, denials list and processes appeals. Posts denials on a timely basis.

• Provides comprehensive denial management to facilitate cash flow. Tracks, quantifies and reports on denied claims.

• Directs and assists with responses to problems or questions regarding benefit eligibility and reimbursement procedures.

• Works credit balance report to ensure adherence to government regulations/guidelines.

• Analyzes claims system reports to ensure underpayments are correctly identified and collected from key carriers. Reviews and resolves billing issues and provides recommendations. Researches unidentified or misdirected payments.

• Identifies and resolves credentialing issues for department physicians.

• Reviews and distributes coding-related information to clinical staff, including CPT and ICD-10/10 code changes, medical necessity policies, coding/billing information on new procedures and devices.

• Trains and mentors less experienced billing staff. Assists area Manager in staff training initiatives.

• Maintains currency in profession on reimbursement trends, coding updates, etc.

• Other duties as assigned.

QUALIFICATIONS

• Associates Degree, or high school diploma/GED.

• 10 years experience in medical billing or health claims, with experience in billing systems in a health care or insurance environment, and familiarity with CPT/ ICD-10/10 coding, preferably in specialized and complex surgical procedures.

846 - Otolaryngology MSH FPA - ISM, Icahn School of Medicine

REQUIRED SKILLS

Communication

Microsoft Office Suite

medical billing

ABOUT US

Strength Through Diversity

The Mount Sinai Health System believes that diversity, equity, and inclusion are key drivers for excellence. We share a common devotion to delivering exceptional patient care. When you join us, you become a part of Mount Sinai’s unrivaled record of achievement, education, and advancement as we revolutionize medicine together. We invite you to participate actively as a part of the Mount Sinai Health System team by:

• Using a lens of equity in all aspects of patient care delivery, education, and research to promote policies and practices to allow opportunities for all to thrive and reach their potential.

• Serving as a role model confronting racist, sexist, or other inappropriate actions by speaking up, challenging exclusionary organizational practices, and standing side-by-side in support of colleagues who experience discrimination.

• Inspiring and fostering an environment of anti-racist behaviors among and between departments and co-workers.

At Mount Sinai, our leaders strive to learn, empower others, and embrace change to further advance equity and improve the well-being of staff, patients, and the organization. We expect our leaders to embrace anti-racism, create a collaborative and respectful environment, and constructively disrupt the status quo to improve the system and enhance care for our patients. We work hard to create an inclusive, welcoming and nurturing work environment where all feel they are valued, belong and are able to advance professionally.

Explore more about this opportunity and how you can help us write a new chapter in our history!

“About the Mount Sinai Health System:

Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 43,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time — discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients’ medical and emotional needs at the center of all treatment. The Health System includes approximately 7,400 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. We are consistently ranked by U.S. News & World Report's Best Hospitals, receiving high "Honor Roll" status, and are highly ranked: No. 1 in Geriatrics and top 20 in Cardiology/Heart Surgery, Diabetes/Endocrinology, Gastroenterology/GI Surgery, Neurology/Neurosurgery, Orthopedics, Pulmonology/Lung Surgery, Rehabilitation, and Urology. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 12 in Ophthalmology. U.S. News & World Report’s “Best Children’s Hospitals” ranks Mount Sinai Kravis Children's Hospital among the country’s best in several pediatric specialties. The Icahn School of Medicine at Mount Sinai is ranked No. 14 nationwide in National Institutes of Health funding and in the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges. Newsweek’s “The World’s Best Smart Hospitals” ranks The Mount Sinai Hospital as No. 1 in New York and in the top five globally, and Mount Sinai Morningside in the top 20 globally.

The Mount Sinai Health System is an equal opportunity employer. We comply with applicable Federal civil rights laws and does not discriminate, exclude, or treat people differently on the basis of race, color, national origin, age, religion, disability, sex, sexual orientation, gender identity, or gender expression. We are passionately committed to addressing racism and its effects on our faculty, staff, students, trainees, patients, visitors, and the communities we serve. Our goal is for Mount Sinai to become an anti-racist health care and learning institution that intentionally addresses structural racism.”

EOE Minorities/Women/Disabled/Veterans

Requisition ID : 3015467