The PB Coder is responsible for reviewing, analyzing, and accurately coding ambulatory and/or hospital-based encounters. This role performs initial charge review for E/M visits, diagnostic tests, and procedures across multiple specialty departments to determine the appropriate assignment of CPT, ICD-10, HCPCS codes, and modifiers for reporting physician services to third-party payers. The PB Coder ensures all coding aligns with established coding standards, regulatory requirements, and reimbursement policies.

Essential Duties and Responsibilities:

• Analyzes provider documentation to assure appropriate Evaluation & Management (E/M) levels are assigned using the correct CPT and current Evaluation and Management Guidelines
•  Analyzes provider documentation to assure that appropriate CPT codes are assigned for surgeries and other diagnostic procedures. Ensures that all coding aligns with coding standards, regulatory requirements and other reimbursement policies such as surgical global package
• Interprets outpatient office visit notes/hospital patient encounters and charge documents to determine services provided and accurately assign CPT, Modifiers, and ICD-10 DX coding to these services
• Performs comprehensive review of all types of encounters to assure all vital information such as patient identification, signatures, attestation, and dates are present in the record. Evaluate documentation for consistency and adequacy. Ensure diagnosis accurately reflects the care and treatment rendered
• Monitors and follows up to ensure all services billed are captured and coded with their assigned coding responsibilities
• Follows and adheres to all WWT policies such as Coding Audit Policy and Physician Coding Query In-Basket Policy
• Provide real time feedback to providers on all coding changes and trends via EPIC in basket message
• Regularly participate and engage all coding meetings and other ad-hoc meetings as needed. Works in coordination with other members of the physician’s office/departments as necessary
• Collaborates with Coding Management Team for special coding and billing projects if assigned
• Resolving coding denials assigned by applying coding knowledge and skills. Apply coding knowledge and skills to resolve coding denials from payers and works with management and various departments
• Maintains active coding credentials and CEU’s required for coding roles
• Performs other related duties as required and assigned

 Knowledge, Skills & Abilities

• Knowledge and understanding of medical coding and billing systems and regulatory requirements
• Communication - communicates clearly and concisely, verbally and in writing
• Persistence – comfortable pursuing, rebutting and escalating issues as appropriate
• Goal-oriented – holds him/herself accountable to achieving shared professional and personal goals.
• Customer orientation - establishes and maintains long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations
• Interpersonal skills – establishing and maintaining effective working relationships with employees, and external parties.
• PC skills - demonstrates high proficiency in Microsoft Office applications, especially Microsoft Excel, and others as required
• Writing skills –advanced writing skills with ability to present a compelling argument, punctuate properly, spell correctly and transcribe accurately

 Education/Experience:

• Certified professional coder CCS-P, CPC, RHIT or RHIA through AAPC or AHIMA with a minimum of two years’ experience with CPT/ICD-10 coding of multispecialty services preferred. Responsible for maintaining continuing education per certification requirements
• Clear understanding of protocols and procedures in a medical office including health information management, confidentiality, and safety
• Organize and prioritize responsibilities while remaining flexible to changing demands
• Excellent written and oral communication skills, with the ability to interact with patients, families, staff and others.
• Strong analytical skills and attention to detail
• Ability to establish priorities and work independently
• Must have high level of discretion and judgment

Position Summary

The Denial Recovery Specialist is responsible for reviewing, analyzing, and resolving denied professional billing claims to ensure accurate and timely reimbursement. This role focuses on identifying root causes of denials, initiating corrective actions, and collaborating with coding, billing, and payer representatives to maximize revenue recovery and reduce future denials.

The ideal candidate demonstrates strong, payer knowledge, and a deep understanding of physician billing guidelines, reimbursement methodologies and analytical skills.

Key Responsibilities

Denial Resolution & Appeals

• Review denied professional claims to determine root cause and appropriate resolution.
• Research payer policies, contracts, and billing guidelines to support appeals.
• Prepare and submit timely, well-documented appeals and reconsiderations.
• Follow up with payers to ensure proper adjudication and payment.
• Track appeal outcomes and identify trends in overturn rates.

Accounts Receivable Management

• Manage assigned A/R workqueues to ensure timely follow-up.
• Prioritize high-dollar and aging claims to optimize cash flow.
• Monitor denial aging and escalate unresolved issues appropriately.

Root Cause Analysis & Prevention

• Identify trends in denials by payer, provider, specialty, CPT, or diagnosis and escalate to management.
• Collaborate with coding and billing teams to address documentation or submission errors.
• Provide feedback to front-end and coding teams to prevent recurring denials.
• Assist in developing process improvements to improve clean claim rates.

Compliance & Accuracy

• Ensure all billing and appeal activities comply with CMS, Medicare, Medicaid, and commercial payer regulations.
• Maintain accurate documentation of actions taken on accounts.
• Protect patient confidentiality in accordance with HIPAA guidelines.

Reporting & Performance Monitoring

• Track and maintain users own productivity and quality metrics.
• Participate in team meetings and training initiatives.

Qualifications

Education

• High school diploma required
• Associate or Bachelor’s degree in Healthcare Administration, Business, or related field preferred

Experience

• 3–5 years of professional medical billing or denial management experience
• Strong knowledge of CPT, ICD-10, HCPCS billing or coding fundamentals
• Experience working with Medicare, Medicaid, and commercial payers
• Familiarity with Epic EHR system

Core Competencies

• Analytical and problem-solving skills
• Knowledge of payer guidelines and reimbursement methodologies
• Detail-oriented with strong documentation skills
• Effective written and verbal communication
• Ability to manage productivity goals and meet deadlines
• Team-oriented with a proactive approach

Position Summary:

The Self-Pay Billing Office (SBO) & Customer Service unit is responsible for responding to all incoming inquiries from patients, departments, various billing agencies and other external inquiries. The representative in this team has frequent contact with patients, Patient Financial Services staff, clinic and hospital staff and management, and managers, as well as billing and professional fee and collection services vendors.

The SBO Customer Service Specialist has a thorough knowledge of WWT & UI Health insurance contracts as the unit deals regularly with complex policy and procedural issues that involve contract compliance regarding HMO, PPO and government payers. Negotiates prompt payment discounts, sets up payment plans according to departmental guidelines, and has a working knowledge of the organization’s discount and charity policy. Provides relevant information to mitigate escalation and 2^nd level disputes.

This position will process all customer service inquiries and follow-ups with quality, compassion and assertiveness. Performs analysis to take appropriate action on information or documents received. Meets WWT & UI Health guidelines, government and HIPAA policies and procedures by utilizing multiple databases and applications.  Applications and Databases consist of: Epic, DataArk (McKesson), Availity, MEDI, On-BaseMS Outlook, MS Excel, MS Word, Medicare Connex, One Source and other payer websites.

Essential Duties and Responsibilities:

• Handles all customer service in-bound call queues for collections, payments, and disputes
• Ensure service levels are met and abandonment rates and RONAs are kept to a min.
• Answers patient concerns regarding the balance inquiries, itemized bill requests and questions about their statements.
• Assist patients with understanding their balance of statements and provide the available payment option that best suits their needs.
• Provides first level financial assistance screening for patients that may qualify for Medicaid coverage or charity care including creating cases for FCMU follow up.
• Updating patient demographics such insurance coverage, address, employer or covered member information.
• Prepares accounts for resubmission of claims to insurance payers when applicable.
• Initiates, route and follow-up on patient disputes regarding charges or coding issues based on workflows.
• Ensures accurate billing practices on patient accounts were applied
• Resolves operational statement hold reasons such as missing address or zip code, credit balances, unbilled coverages, etc.
• Research and resolve a minimum of 25 accounts or guarantor accounts daily from WQ’s for DNBI, Fin. Assist screening, coverage changes, etc.
• Responds to patient inquiries/concerns received by telephone or mail within 48 hours not to exceed 30 days of receipt.
• Clarifies understanding of the inquiry/concern, determines the appropriate course of action, initiates and/or completes appropriate action, resolves patient complaints and does appropriate customer service recovery when required.
• Research and processes accounts subject to bankruptcy regulations or legal actions.
• Running individual time log reports to ensure effective time management and efficiency.
• Other duties as assigned

 Knowledge, Skills & Abilities

• Previous call center or customer service experience in the medical field required.
• Working knowledge of Epic is preferred.
• Demonstrate an in-depth understanding of all aspects of billing procedures consistent with those performing insurance follow-up activities both hospital and professional billing environment

• Working knowledge of insurance billing requirements, UB04 and HCFA 1500 claim forms, EOBs, Workers’ Compensation, Personal Injury, HMOs, PPOs, MCO, Medicare, Medicaid and compliance program regulations.
• Basic understanding of CPT, ICD, DRG, and HCPC codes.
• Excellent interpersonal, verbal, and written communication skills
• Ability to demonstrate cultural sensitivity and a respectful, courteous and professional manner in all interactions
• Ability to balance assertiveness with compassion, empathy and patience for the patient and others
• Ability to effectively handle difficult customer situations on the phone and de-escalate the situation.
• Critical thinking and use good judgment in decision making.
• Good analytical and organizational skills
• Motivated individual with a positive outlook and exceptional work ethic
• Ability to consistently follow direction, processes and written procedures
• Thorough knowledge of computer operation, keyboard functions, calculator, copier and fax machine operation with standard keyboard skills
• Computer software skills (i.e. Microsoft Applications and E-mail, etc.)
• Thorough understanding of HIPAA rules and regulations
• Bi-lingual Spanish-speaking a preferred
• Self-starter with strong sense of ownership, assertive follow-through and orientation toward results.

 Education/Experience:
High School diploma or equivalent required. Experience should demonstrate expert level knowledge of analyzing and resolve complex problems in a quick and effective manner. Must have the ability to analyze and interpret data, good problem-solving skills and initiative. Experience should also demonstrate the use of effective communication skills with patients and staff; demonstrate proper telephone techniques and etiquette; shows sensitivity to differences of culture; demonstrates a positive and supportive manner in which patients / families/ colleagues perceive interactions as positive and supportive. Exhibits teamwork skills to positively acknowledge and recognize other colleagues and uses personal experiences to model and teach within organizations standards.