If you are interested in joining the SunStone Consulting team, please send your resume and the position your are applying for to inquiries@sunstoneconsulting.com.
Senior Consultant Professional/Outpatient (RI)
Job Description
Senior-level professional with in-depth professional or hospital outpatient documentation, coding, and billing auditing experience within a workplace culture that emphasizes open communication and opportunities for growth. Must be highly organized and possess professional or outpatient coding certifications with specific experience reviewing documentation, coding and billing of physician charges. The ideal candidate can work independently in a home office setting, is a problem-solver and effective communicator, taking on challenges independently with a strong attention to detail, who enjoys working in a collaborative and team-based environment.
Responsibilities
Utilizing their knowledge of professional and/or outpatient coding, conducts compliance related documentation, coding, and billing audits to identify coding and/or clinical documentation improvement opportunities using professional coding standards and regulatory guidance.
Applies comprehensive knowledge of Medicare and Medicaid guidelines under the Medicare Physician Fee Schedule, Conditions of Participation, state healthcare regulations, and official coding guidelines for ICD-10-CM and CPT to compliance audits.
Demonstrates expertise in utilizing regulatory coding resources such as AMA E/M guidelines, CPT Assistant, NCCI, and Coding Clinics relative to physician charges.
Prepares accurate and thorough claim review finding workpapers, with notation of regulatory documentation references utilized to support findings during the audit, while also maintaining greater than 95% accuracy of physician charges.
Demonstrates an ability to collaborate well with others on the review team, sharing insights and uncovering opportunities and/or compliance risk.
Conducts research surrounding governmental or third-party payer guidelines by evaluating applicable coding guidelines, LCD’s, NCD’s and any applicable CMS or payer guidelines. Ability to articulate research findings in a cohesive, well written manner for ease of client interpretation.
Assists with the development of educational material and conducts education with clients on clinical documentation and professional and technical charge capture and coding opportunities, to include practitioners, clinical staff, allied health professionals and coders.
Conducts reviews to assess the accuracy of professional and technical CDM for services requiring CPT/HCPCS codes, to include compliance with governmental guidelines and regulations.
Qualifications
Bachelor’s degree with a minimum of 10+ years of multi-entity health information and/or clinical/auditing experience of physician and outpatient technical billing.
Certified Procedural Coder (CPC) or Certified Outpatient Coding (COC) or Certified Coding Specialist (CCS), or Certified Coding Associate (CCA) by the American Health Information Management Association (AHIMA) and the American Academy of Professional Coders (AAPC) or Registered Nurse (RN).
Knowledge of anatomy, physiology and medical terminology commensurate with the ability to correctly code various types of and diagnoses.
Ability to communicate and collaborate effectively with managers, clients, and team members.
Demonstrates independent judgment, discretion, accuracy, analytical skills and decision-making abilities.
Proficient in Microsoft Office Suite including Word, Excel, PowerPoint, SharePoint and e-mail application.
Experience in the healthcare finance, revenue cycle and/or payer contracting and reimbursement, as well as a strong business acumen, critical thinking proficiency, and strong communication skills. SunStone values ingeunity within each team members role which enable us to conntinually enhance our solutions. An essential ingredient to our success is understanding the critical balance between work and home.
Responsibilities
Understand the intricacies of governmental and third party payer reimbursement models for both hospitals and provider practices.
Evaluate third party payer contract information received from client, and model contract terms and/or reimbursement in an accurate manner.
Develop payer specific rate packages based on the scope of work for each engagement.
Be attentive for improvements to internal process improvement opportunities, as well as opportunities to enhance client processes.
Collaborate effectively, participating in cross-functional meetings with Service Lines and IT to ensure superior results.
Continually validate processes, troubleshooting when necessary, to ensure client objectives.
Assist with other reporting and analysis needs, such as data analytics and sampling, maintaining processes/specifications to ensure repeatability.
Assist with the development of non-standard reporting, being attentive to new processes that will transform our solutions.
Qualifications
Associate or bachelor’s degree in finance, business or economics with a minimum of 5+ years of multi-entity health system and/or related degree or experience.
Job duties are project-based, working collaboratively with managers, team members and multiple Service Lines and IT.
Proficient with advanced Excel skills (i.e., pivot tables, v-lookups, charts, etc.).
Exposure to data tools such as Power BI and SQL is beneficial, though not mandatory.Ability to handle multiple projects and deadlines with an attention to detail and ability to follow instructions to deliver superior results.
Demonstrates independent judgment, discretion, accuracy, analytical skills and decision-making abilities.
What You’ll Do:
Lead and manage a team of billing specialists, providing guidance, support, and training as needed.
Oversee the entire medical billing process, from claim submission to payment collection, ensuring accuracy, timeliness, and compliance with relevant regulations.
Monitor and analyze billing data to identify trends, issues, and areas for improvement, and implement necessary changes to optimize billing operations.
Collaborate with other departments, such as coding and finance, to resolve billing-related inquiries, discrepancies, and issues.
Develop and enforce billing policies and procedures to ensure adherence to industry standards and regulations.
Stay updated with changes in medical billing regulations, coding guidelines, and insurance policies, and ensure that the team is trained accordingly.
Conduct regular audits of billing processes and records to identify and rectify errors, discrepancies, and potential areas of non-compliance.
Generate and analyze billing reports to assess team performance, identify areas for improvement, and provide recommendations for increased efficiency and productivity.
Participate in meetings and communicate with management and stakeholders to provide updates on billing operations, challenges, and achievements.
Maintain confidentiality of patient records and sensitive billing information, ensuring compliance with HIPAA regulations.
What You Bring:
Strong leadership skills, with the ability to motivate and supervise a team effectively.
Excellent knowledge of medical billing procedures, coding systems, and insurance regulations.
Proficient in using EPIC medical billing software and electronic health record (EHR) systems.
Attention to detail and strong analytical skills to identify and resolve billing-related issues and discrepancies.
Excellent communication and interpersonal skills to effectively collaborate with team members, management, and clients.
Ability to work in a fast-paced environment and handle multiple tasks simultaneously, while maintaining a high level of accuracy and efficiency.
Strong organizational and time management skills to prioritize tasks and meet deadlines.
Problem-solving skills to address billing-related challenges and implement effective solutions.
Knowledge of industry best practices, emerging trends, and technological advancements in medical billing.
Proficient in Microsoft Office Suite, particularly Excel, for data analysis and reporting.
Required Qualifications:
Bachelor's degree in healthcare administration, finance, or a related field.
Minimum of 3-5 years of experience in medical billing, preferably in a supervisory or leadership role.
Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification is preferred.
Solid understanding of medical terminology, ICD-10, CPT, and HCPCS coding systems.
Familiarity with insurance claim forms, such as CMS-1500 and UB-04.
Knowledge of HIPAA regulations and compliance requirements in medical billing.
Experience with billing software and EHR systems, such as Epic, Meditech, or Cerner, is required.
Strong knowledge of medical billing software, such as Medisoft or Kareo, and proficiency in using billing clearinghouses.
Experience in managing and resolving complex billing issues and denials.
Strong understanding of revenue cycle management and its impact on the financial health of healthcare organizations.
Preferred Qualifications (Bonus Points!):
3+ years of experience in a medical billing supervisory role.
Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification.
Work Environment & Physical Demands:
This is a remote, home-office based position.
You’ll utilize standard office equipment (laptops, smartphones, etc.)
Typical work hours are 8:00 am – 5:00pm, Monday through Friday.
No travel is expeted
Why Join Us?
Growth Opportunities: Expand your skills and advance your career.
Flexibility: Enjoy the convenience of a remote work environment.
Impactful Work: Co
Collaborative Team: Work alongside a supportive and knowledgeable team.