Charge Capture and Claim Submission

• Review and verify charges, CPT/ICD-10/HCPCS codes, and modifiers for orthopedic office visits, procedures, injections, imaging, DME, and surgical services before billing.
• Prepare, scrub, and submit clean claims to commercial, government, and third-party payers through athenaOne, resolving claim edits and clearinghouse rejections promptly.
• Track global surgical periods, bundling rules, and payer-specific requirements to ensure correct billing for orthopedic procedures.

Denial Management and Appeals

• Work denials, rejections, kicked claims, and no-response claims daily in athenaOne; determine the kick reason and root cause, correct, and resubmit within payer timely-filing limits.
• Draft and submit appeals with supporting documentation, including for medical-necessity, authorization, coordination-of-benefits, and downcoding denials common in orthopedics.
• Route registration-driven denials (eligibility, coordination of benefits, authorization) back to the front desk so they are fixed at check-in, and track denial trends for the CFO.

Accounts Receivable Follow-Up

• Work aging reports and claim-notes productivity queues daily to keep days in A/R and over-90 balances within target.
• Work with Athena one on outstanding and slow-adjudicating claims, document all activity in claim notes, and escalate stalled or high-dollar accounts.
• Monitor payer underpayments against expected contracted rates and pursue corrections.

Central Billing Office Coordination

• Insurance payments are posted centrally by the central billing office; this role does not post insurance payments. The biller monitors and reconciles that posted activity rather than keying insurance payments.

• Work claims held in hold queues, identifying the reason and owner, and drive them to release.

• Serve as the practice's point of contact with the central billing office on holds, escalations, and unresolved claims.

Private-Pay and Patient Collections

• Own private-pay and patient-responsibility collections, including collecting and posting patient payments.
• Answer billing questions and set up payment arrangements and plans.
• Coordinate with the front desk on time-of-service collections, deductible estimates, and point-of-service payment to lift the patient collection rate.
• Resolve patient billing disputes and coordinate refunds or write-offs per practice policy.

Insurance Verification and Support

• Verify eligibility, benefits, and authorization/referral requirements as needed to prevent front-end denials.
• Coordinate with providers and clinical staff to obtain documentation supporting billed services.

Compliance and Reporting

• Maintain billing practices in compliance with HIPAA, payer rules, and applicable coding and billing regulations, including NCCI edits, Medicare LCD/NCD policy, and workers' compensation standards.
• Support month-end close by keeping charges, private-pay payments, and claim activity current, and provide billing reports and KPI tracking to the CFO as requested.

• Two or more years of hands-on medical billing experience, including direct orthopedic billing experience.
• Proficiency in athenaOne (athenahealth) is required. Candidates must be able to work claims, denials, holds, and A/R follow-up within athenaOne with minimal ramp-up.
• Working knowledge of CPT, ICD-10, and HCPCS coding and modifiers as applied to orthopedic and musculoskeletal services.
• Demonstrated experience with denial management, appeals, and payer follow-up.
• Experience collecting and posting private-pay and patient-responsibility balances, including statements and payment plans.
• Strong understanding of the full revenue cycle and of commercial and government payer requirements.
• High school diploma or equivalent.
• Accuracy, organization, and the ability to manage a high claim volume independently.

Preferred Qualifications

• Certified Professional Biller (CPB) or Certified Professional Coder (CPC) credential.
• Experience billing for orthopedic subspecialties, ambulatory surgery center (ASC), or surgical claims.
• Familiarity with workers' compensation and personal-injury/PIP billing.
• Experience with contracted-rate analysis and underpayment recovery.
• Experience working with a central-billing-office (CBO) model.

Skills and Attributes

• Detail-oriented and self-directed, with strong follow-through on open claims and balances.
• Clear, professional communicator with patients and payers.
• Comfortable working with billing reports, spreadsheets, and productivity metrics.
• Dependable, discreet, and committed to protecting patient information.

Work Environment and Physical Requirements

• Remote position. Requires a private, HIPAA-compliant workspace and reliable high-speed internet.
• Prolonged periods of sitting and working at a computer, with frequent use of a keyboard, monitor, and telephone.
• Must be able to communicate clearly by phone and in writing with patients, payers, and staff.