SUMMARY:

The Electronic Data Interchange Specialist will be responsible for assuring all claims that are processed through Electronic Medical Records and Practice Management Software are correctly billed and compliant. Validation through claim edit software before processing to the clearinghouse is essential. The Electronic Data Interchange Specialist will conduct random audits for proper coding of CPT codes vs. diagnosis codes and therefore must stay current with all insurance policy, CPT, HCPCS, and ICD-10-CM code changes throughout the year.

EDUCATION/CERTIFICATIONS & LICENSES:

• High School diploma or GED required.
• CPB, CPC, CPC-A, CCS, or CHONC preferred.

EXPERIENCE:

• Minimum of two (2) years of experience in medical billing, coding, or insurance collections required.
• Ability to read and interpret documents such as payer medical policies and explanation of benefits (EOB).
• Understanding of insurance billing process and claim form completion.
• Knowledge of medical terminology, coding terminology (CPT, ICD-10-CM, HCPCS), and insurance/reimbursement practices.
• Medical Oncology, Radiology, Radiation, Laboratory, or Pathology experience preferred.

CORE COMPETENCIES, KNOWLEDGE/SKILLS/ABILITIES:

• Analysis & Critical Thinking
• Strong interpersonal skills to include effective verbal and written communication
• Solid time management with the ability to prioritize multiple tasks
• Ability to collaborate across various levels of management, departments, and teams
• Comfortable negotiating problems and exploring solutions with physician population

• Be able to meet daily, weekly, monthly production and quality standards set for the position.
• Follow up on complex insurance denials or unpaid insurance balances.
• File appeals and update patient demographics.
• Identify trends and report up.
• General knowledge and application of Medicare, Medicaid, Commercial insurance guidelines, claims appeal processes.
• Performs other duties and projects as needed.