Billing Specialist

Position Summary
TheBilling Specialist drives the continuous optimization of the end-to-end financial workflows and safeguards the financial integrity of Charter Oak Health Center. Operating within a Federally Qualified Health Center (FQHC) model, this position manages complex medical claims from encounter closure through final adjudication using theeClinicalWorks (eCW) electronic medical record (EMR) and practice management platforms.

Key objectives include safeguarding net revenue capture, maximizingclean claim rates, accelerating cash flow, and proactively managing underpayments and denials. The Revenue Cycle Specialist minimizes revenue leakage, actively reducesDays Sales Outstanding (DSO), and ensures strict adherence to HRSA guidelines, Medicaid/Medicare regulations, and HIPAA compliance laws.

Essential Position Duties

1. Claims Management & Front-End Revenue Capture

• Daily Claim Auditing: Review, scrub, and validate high-volume medical, dental, and behavioral health encounters within eClinicalWorks to ensure structural and regulatory compliance prior to payer submission.
• Coding Integrity & Quality Assurance: Audit clinical charts to ensure exact alignment with ICD-10-CM, CPT, and HCPCS Level II coding guidelines, validating proper documentation of modifiers, time-based codes, and FQHC encounter triggers.
• Clearinghouse Exception Management: Monitor and instantly correct electronic front-end edits and clearinghouse rejections to prevent workflow bottlenecks and maintain a clean claim target of >95%.
• Data Optimization: Review, append, and modify patient demographic profiles, insurance coordination of benefits (COB), and sliding fee scale tiers within the practice management system to guarantee accurate upfront adjudication.
• Bottleneck Escalation: Isolate and flag open encounters missing provider signatures, clinical charts, or documentation anomalies, escalating them systematically to providers and the Revenue Cycle Manager to preserve timely filing windows.

2. Denial Management & Accounts Receivable (A/R) Optimization

• Proactive Denial Resolution: Identify, trend, and appeal unpaid or rejected claims by researching payer-specific policies, utilizing advanced electronic health records (EHR) tools, and executing formal redetermination requests.
• A/R Aging Management: Aggressively audit outstanding insurance balances within designated 30-, 60-, 90-, and 120+ day aging buckets; formulate strategic follow-up queues to extract overdue reimbursements.
• Underpayment & Variance Tracking: Review electronic remittance advices (ERAs) and explanation of benefits (EOBs) against FQHC Prospective Payment System (PPS) rate schedules to detect underpayments or unauthorized contractual adjustive variances.
• Payer Policy Surveillance: Stay current on evolving commercial, Medicaid, and Medicare coverage policies, state filing limitations, and regulatory changes to adjust internal front-end system edits dynamically.
• Root-Cause Denial Analysis: Review, categorize, and track inbound claim denials within eClinicalWorks (eCW) using standard CARC (Claim Adjustment Reason Codes) and RARC (Remittance Advice Remark Codes) to identify systemic front-end or clinical documentation vulnerabilities.
• End-to-End Appeal Execution: Draft, assemble, and submit comprehensive, evidence-based appeal packets—including clinical notes, proof of timely filing, and medical necessity documentation—to overturn erroneous payer denials and secure maximum reimbursement.

3. Payment Posting & Financial Reconciliation

• Review the posting of all insurance payments and contractual adjustments for accuracy; communicate and resolve any payment discrepancies.
• Process and accurately post patient credit card payments, checks, and cash transactions.
• Make appropriate financial adjustments, transfer patient balances, and perform fee write-offs in accordance with practice protocols.
• Reconcile daily payment postings and accounts receivable.
• Prepare and complete daily bank deposits accurately and maintain cash accountability.
• Process patient refunds efficiently upon verification of credit balances.

4. Accounts Receivable & Denials Management

• Regularly follow up on outstanding accounts receivable balances for both insurance payers and self-pay patients.
• Initiate inquiries and appeals on questionable claim denials, rejections, or unexpected payment adjustments.
• Monitor aging accounts receivable reports to identify trends, root causes for non-payment, and systemic billing issues.
• Maintain up-to-date knowledge of third-party payer guidelines, billing updates, and healthcare regulations impacting claim processing.

5. Patient Financial Counseling & Customer Service

• Answer inquiries promptly, courteously, and professionally from patients, insurance carriers, and staff regarding accounts and billing statements.
• Counsel patients regarding high-deductible policies, co-insurance responsibilities, payment plans, and expectations for payment.
• Assist front office staff with insurance verification, fee schedule inquiries, and patient balance clarity to support smooth check-in and checkout workflows.

• Manage billing-related telephone calls and written correspondence in a clear and empathetic manner.

Qualifications

Education & Experience

• High School Diploma or GED required; an Associate's or Bachelor's degree in Healthcare Administration, Finance, or Accounting is highly preferred.
• Minimum of 2–3 years of direct healthcare billing and revenue cycle experience within a hospital, high-volume physician practice, or Federally Qualified Health Center (FQHC).
• Proficiency in eClinicalWorks (eCW) or a comparable top-tier enterprise EHR system (e.g., Epic, NextGen) is required.

Certifications (Preferred)

• Certified Revenue Cycle Specialist (CRCS) via AAHAM
• Certified Professional Coder (CPC) via AAPC
• Certified Medical Reimbursement Specialist (CMRS)