Job Summary:

Responsible for the accounts receivable functions related to professional fee billing. Performs all procedures for assigned accounts, including charge entry, claims processing, line-item payment posting, denial management, and resolution of insurer payment discrepancies. Coordinate claims editing software and application processes for identifying and correcting claims submission/payment errors. Investigates and analyzes payer remittance advice regarding denials and reimbursement discrepancies. Obtain pre-certifications for biologic/infusion drugs in accordance with insurance requirements. 

This position is also responsible for facilitating in problem-solving, correctly answering questions, providing information and coordinating communication between patients and/or family members and the appropriate staff. This position provides support and assistance to families receiving care and services. To inform the Clinical and Administrative team of problems facing these families that might create barriers to treatment. The Patient Advocate provides services to patients and their families to support and maximize all financial functioning and care of the patient, serves as a liaison between the patient and the medical staff. 

Principal Duties: 

Assists the billing department with various assignments; including but not limited to pre-authorizations, insurance verification, charge auditing, payments, posting, and other requests

Creates new codes, manages NDC updates, and maintains fee schedule quarterly for biologic/infusion drugs and carrier changes.

Obtain appropriate authorization from third-party payers for services requiring such authorization.

Monitors insurance carrier reimbursement to ensure maximum and expected reimbursement is received. Manage denials for all department services.

Facilitates practice management system edit creations or revisions to ensure accurate claim submission.

Maintains current knowledge and educates providers and staff on coding changes and new insurance regulations.

Audits department charges to ensure accurate billing; provides education to physicians and staff on improper coding.

Monitors replacement drug shipments, and coordinates all drug replacement for future dates of service.

Notify clinical staff of patient financial issues affecting treatment. Facilitate enrollment to industry-sponsored product procurement programs when appropriate. Facilitate and/or refer patients and families to support/education groups, whenever possible.

Analyze and provide information and facilitate referrals to community, private, state, and federal agencies based on need (e.g. financial programs, medication assistance programs, financial assistance programs, and transportation resources)

Attends required meetings and participates in committees as requested.

Typical Physical Demands:

Requires full range of motion including, manual and finger dexterity and eye-hand coordination.  Occasionally lifts and carries items weighing up to 30 pounds.  Requires corrected vision and hearing to normal range.  

Performance Requirements:

Applicant should be detail-oriented with excellent communication skills. The position will require interaction with patients, insurance carriers, providers and outside vendors. Knowledge of organizational policies, regulations, and procedures to administer billing and compliance protocols.  Knowledge of medical terminology.  Skill in identifying problems and recommending solutions.  Skill in preparing and maintaining records, writing reports, and responding to correspondence.  Skill in developing and maintaining department quality assurance.  Skill in establishing and maintaining effective working relationships with patients, medical staff, and the public.  Ability to maintain quality control standards.  Ability to react calmly and effectively in emergency situations. Ability to interpret, adapt, and apply guidelines and procedures. Ability to communicate clearly.  Working knowledge of Medicare and Medicaid legislation and third-party payer contracts. Demonstrate knowledge of how these programs/regulations affect the functions and role of the business; the ability to incorporate them into departmental systems/processes. 


Associate or College degree preferred. 


Two years professional fee billing experience directed toward accounts receivable management, automated patient accounts systems, and insurance recovery processes. Experience and familiarity with revenue cycle process with primary emphasis on data entry, claims processing, line-item payment processing, and insurance appeals. Familiar with billing/coding process and prior experience operating automated physician-billing systems.

Minimum of one year experience working with commercial, Medicare, and HMO insurance procedures

Alternative to Minimum Qualifications:

Additional experience may be alternative to degree requirement