Position Description:
Our busy, growing retina practice is seeking an experienced Medical Billing Specialist to join our revenue cycle team. The ideal candidate will have extensive knowledge of ophthalmology or retina billing and a proven ability to maximize reimbursement through effective claims management, denial resolution, appeals, and buy-and-bill prior authorization processes.
This position plays a critical role in ensuring timely reimbursement while maintaining compliance with payer guidelines and industry regulations.
Essential Responsibilities:
- Manage insurance claim submissions, payment posting, and accounts receivable follow-up.
- Investigate, resolve, and appeal denied or underpaid medical claims with commercial insurers, Medicare, and Medicaid.
- Prepare and submit comprehensive first-level and second-level appeals, including supporting medical documentation and payer-specific requirements.
- Monitor payer trends and identify root causes of claim denials to improve clean claim rates.
- Obtain and manage prior authorizations for buy-and-bill medications and procedures, including retina pharmaceuticals such as anti-VEGF injections.
- Verify insurance benefits and coverage for specialty medications and procedures.
- Communicate with physicians, technicians, and clinical staff to obtain documentation necessary for claims and appeals.
- Maintain accurate documentation of payer communications and authorization status.
- Monitor aging reports and prioritize high-dollar outstanding accounts.
- Stay current on CPT, ICD-10-CM, HCPCS, Medicare, and commercial payer billing guidelines.
- Assist with revenue cycle improvement initiatives and workflow optimization.
Qualifications
Minimum of 2 years of medical billing experience, preferably in ophthalmology or retina.
Strong experience with:
Insurance claim denials and denial management
Medical necessity appeals
Buy-and-bill prior authorizations
Medicare and commercial insurance billing
Accounts receivable follow-up
Working knowledge of CPT, ICD-10-CM, HCPCS, and modifier usage.
Experience with electronic medical records (EMR) and practice management software.
Excellent analytical, organizational, and problem-solving skills.
Strong written and verbal communication skills.
Ability to work independently while managing multiple priorities.
Preferred Qualifications:
- Retina or ophthalmology billing experience.
- Experience with specialty pharmaceutical reimbursement and buy-and-bill workflows.
- Knowledge of anti-VEGF medications and payer coverage requirements.
- Certified Professional Biller (CPB) or Certified Professional Coder (CPC) certification is a plus.
We Offer:
- Competitive salary based on experience
- Comprehensive benefits package
- Paid time off and holidays
- Retirement plan with employer contribution
- Professional development opportunities
- Supportive, team-oriented work environment
If you are detail-oriented, enjoy solving complex reimbursement challenges, and have a passion for maximizing revenue through effective denial management and prior authorization expertise, we encourage you to apply.
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