Overlapping Coding Claims Specialist - 40 hrs/wk, 1st shift

About the Role

The Overlapping Coding Claims Specialist is responsible for reviewing, correcting, consolidating, and supporting the submission of claims involving overlapping encounters across multiple billing entities. This role ensures compliance with payer regulations regarding same-day services, 24-hour and 72-hour billing requirements, and medical necessity standards. The specialist analyzes encounters for medical relation, determines appropriate encounter combinations, moves diagnoses and charges as needed, and supports the submission of accurate claims for reimbursement.

Responsibilities

• Identify encounters that meet 24-hour and 72-hour billing consolidation requirements based on date of service, admission/discharge timing, entity, and payer-specific billing requirements. Identify "from" and "to" encounters when combining, moving, or consolidating services.
• Evaluate medical records and billing documentation to determine whether encounters are medically related.
• Move and/or combine diagnosis codes to ensure accurate claim representation and compliance with coding guidelines.
• Review, combine, or transfer charges between encounters, as appropriate, based on payer regulations and organizational policies.
• Consolidate claims when required to meet payer billing requirements. Provide support to the billing team in releasing claims to insurance for payment.
• Review and resolve claims issues through Quadax related to the 72/24-hour overlapping rules and medical relation.
• Work collaboratively with coding, revenue integrity, patient access, PFS, and clinical departments to resolve billing issues.
• Participate in daily huddles, idea board meetings, staff meetings, and meetings with external departments to manage daily improvements.
• Communicate professionally with patients, third-party payor representatives, provider relations, contract management, and other internal/external stakeholders to achieve revenue cycle AR goals.
• Maintain current knowledge of Medicare, Medicaid, and commercial payer regulations related to overlapping encounters and bundled billing requirements.
• Ensure services comply with state and federal regulations, organizational policies, and compliance requirements. Maintain compliance with HIPAA and institutional policies regarding patient information and financial data.

Requirements

• High school diploma or GED equivalent.
• One (1)+ year of coding experience or completed education in a medical coding/billing program.
• Two (2)+ years of UB/facility billing experience.
• Strong knowledge of UB billing regulations and claim submission processes.
• CPC, CCS, or CCA certification (or obtained within the first 6 months of hire).
• CPFSS certification within 12 months of hire.
• Ability to analyze medical records and determine medical relation between encounters.
• Demonstrated knowledge of medical terminology, anatomy, and physiology as it relates to healthcare billing, coding, and reimbursement.
• Knowledge of revenue codes, CPT/APC/HCPCS, ICD/DRG coding, NCCI, HIPAA, and other applicable concepts.
• Knowledge of CMS 1500 forms, UB-04’s, remittance advice, and itemized statements.
• Knowledge of revenue cycle workflows and systems such as Cerner, Trisus, Forvis, Quadax, KaiNexus, 3M, and Experian.
• Regulatory compliance and reimbursement methodologies knowledge.
• Ability to research, review, analyze, and interpret federal, state, and local billing regulations.
• Ability to compile, analyze, and present data and complex information effectively to various audiences, including leadership.
• Ability to manage complex issues and multiple tasks/projects.
• Excellent organizational, time management, and follow-through skills; detail-oriented.
• Self-directed with strong problem-solving, research, and analytical skills.
• Positive service-oriented interpersonal and communication skills for interacting with all levels of the organization, including senior leadership.

Preferred Qualifications

• Associate’s degree in a healthcare-related field.
• Certified Professional Biller (CPB) certification.

Physical Demands

This position requires a full range of body motion with intermittent walking, lifting, bending, squatting, kneeling, twisting, and standing. The associate will walk for up to one hour a day, sit continuously for six hours a day, and stand for one hour a day. The individual must lift twenty to fifty pounds and reach work above the shoulders. Fine finger dexterity and good eye-hand coordination are required for simple grasping tasks. Corrected vision and hearing in the normal range are necessary. The individual must operate a motor vehicle for business travel and community involvement.