COMPANY OVERVIEW
Duffy Health Center, a non-profit located in Hyannis, MA, provides compassionate and skilled integrated healthcare for persons with complex health and social needs on Cape Cod. We envision a Cape Cod where all persons have access to quality health care, safe and stable housing, and lives filled with connection and purpose.
Duffy Health Center is a Federally Designated Healthcare for the Homeless Program, which requires that most of the patients we serve are experiencing or have recently experienced homelessness or some other form of housing insecurity.
Staff choose to work here because they believe deeply in the mission, and some staff have relevant lived experience themselves. The Medical Director should be a highly skilled and empathetic clinician who has a specific interest and relevant experience in working with complex populations such as ours.
JOB OVERVIEW
The Billing and Revenue Management Specialist is responsible for preparing, submitting, and following up on claims for services rendered across all service lines at Duffy Health Center. This role ensures timely and compliant billing to Medicaid, Medicare, commercial insurers, and other payers, in accordance with FQHC-specific regulations and guidelines. The Medical Biller plays a critical role in optimizing reimbursement and supporting the financial sustainability of the organization through accurate claims management, payment posting, and payer follow-up.
Thel Billing and Revenue Management Specialist is a key member of the Revenue Cycle and Financial Operations team at our Federally Qualified Health Center (FQHC). This role ensures the timely and accurate processing of claims, effective accounts receivable (A/R) management, patient balance follow-up, and the administration of the sliding fee scale. The Specialist plays a crucial role in supporting high-quality, value-based, and population-focused care by maintaining financial integrity and contributing to accurate data capture for quality reporting. The ideal candidate is detail-oriented, patient-focused, and understands the unique billing environment of FQHCs.
KEY RESPONSIBILITIES
The Medical Biller is responsible for the following core functions:
Revenue Cycle Management & Financial Operations
- Submit accurate and timely claims to Medicare, Medicaid, and commercial insurance payers in accordance with FQHC billing regulations.
- Monitor and patient insurance eligibility process in collaboration with the Patient Access Manager
- Monitor and manage the EDI processes to ensure accurate payer set-up
- Monitor payer rejections and submit tickets for identified claims issues
- Post payments and reconcile ERAs, EOBs, and patient payments promptly and accurately.
- Monitor and manage A/R, ensuring effective follow-up on unpaid, underpaid, and denied claims.
- Review, correct, and resubmit rejected or denied claims to ensure timely reimbursement.
- Process credit balances, patient refunds, and adjustments in accordance with internal policies and payer rules.
- Apply sliding fee scale discounts based on documented eligibility and ensure accurate reflection in billing systems.
- Maintain detailed records of billing activity, correspondence, and payment histories.
Patient Copay, Self-Pay, and Payment Plan Management
- Verify, collect, and post patient copays at the time of service or during billing follow-up.
- Manage self-pay patient accounts, applying appropriate discounts and assisting with financial counseling.
- Work with patients to establish and manage payment plans that comply with center policy and reflect their ability to pay.
- Educate patients on available financial assistance options, including sliding scale eligibility and community resources.
- Monitor payment plans to ensure timely payments and follow up with patients on missed or partial payments.
Refusal-to-Pay Management
- Address patient refusal-to-pay scenarios with empathy and professionalism, offering alternative solutions such as payment plans or financial assistance.
- Document all interactions and escalate unresolved issues according to center policy.
- Collaborate with internal departments (e.g., case management or social services) to help patients overcome financial barriers to care.
Value-Based Care, Population Health & Quality Integration
- Ensure accurate capture of coding and billing data that supports quality and population health metrics (e.g., HCC coding, risk adjustment).
- Partner with Quality and Population Health teams to contribute data for UDS, HEDIS, and value-based reimbursement programs.
- Help ensure billing practices support patient-centered care and align with value-based care contracts and reporting requirements.
- Support initiatives that improve reimbursement accuracy and organizational revenue integrity.
Compliance & Continuous Improvement
- Maintain up-to-date knowledge of FQHC billing rules, HIPAA, and payer-specific requirements.
- Participate in audits, compliance reviews, and internal training related to billing accuracy and workflow efficiency.
- Identify opportunities for improvement in billing processes and patient financial engagement strategies.
Denial & Reimbursement
· Analyze denied, underpaid, and rejected claims to identify root causes and recurring trends
· Coordinate with payers and internal departments to resolve reimbursement issues
· Support payer audits and requests for medical records or additional documentation related to denied claims
· Submit appeals, corrected claims, and reconsideration requests in accordance with payer guidelines and filing deadlines.
· Monitor payer-specific denial trends and recommend workflow improvements to reduce future denials.
- Prepare and submit accurate, timely claims to Medicaid, Medicare, and commercial insurers.
- Review and verify billing data for accuracy and completeness before claim submission.
- Ensure that electronic medical records (EMRs) support compliant and appropriate billing.
- Follow up on unpaid or denied claims within the billing cycle timeframe.
- Collaborate with payers, providers, and internal departments to resolve billing discrepancies.
- Accurately post payments, adjustments, and write-offs in a timely manner.
- Apply knowledge of FQHC-specific billing practices, including PPS rates and wrap-around payments.
- Stay current on payer guidelines, FQHC billing regulations, and HRSA compliance requirements.
- Assist with internal and external audits, reporting, and revenue cycle analysis as needed.
- Coordinate with front desk and clinical staff to ensure accurate data capture and insurance verification.
- Provide support for credentialing and payer enrollment processes as needed.
- Uphold patient confidentiality and compliance with HIPAA standards in all billing activities.
QUALIFICATIONS & SKILLS
Education & Experience:
- High School diploma or equivelent
- At least 2 years of medical billing experience required; FQHC billing experience highly preferred.
- Proficiency in CPT, ICD-10, and HCPCS coding.
- Experience working with Electronic Health Records (EHR).
Skills & Competencies:
- Strong understanding of healthcare billing processes, payer rules, and reimbursement systems.
- High level of accuracy and attention to detail in data entry and claim preparation.
- Effective communication and interpersonal skills for collaboration across departments and with external payers.
- Ability to prioritize tasks and meet deadlines in a fast-paced healthcare environment.
- Proficiency in Microsoft Office applications and billing/revenue cycle software tools.
- High school diploma or equivalent required; associate degree or certification in medical billing/coding or healthcare administration preferred.
- Certified Professional Biller (CPB), Certified Professional Coder (CPC), or equivalent certification preferred.
- Minimum 2 years of billing experience in a healthcare setting; FQHC or community health center experience strongly preferred.
- Strong working knowledge of insurance claims processing, A/R management, sliding fee scale policies, and payment plan administration.
- Familiarity with value-based care models, quality reporting programs (e.g., UDS, HEDIS), and population health concepts.
- Experience with EHR/practice management systems (e.g., Epic).
- Excellent customer service, problem-solving, and communication skills.
- Ability to handle sensitive financial conversations with compassion, confidentiality, and professionalism.
Work Environment: Primarily office-based within a community health center setting, opportunities for remote work depending on organizational policies, and regular interaction with both clinical and administrative staff.
- Standard office or remote work environment depending on organizational policies.
- Regular communication with clinical, quality, and finance departments.
- May require occasional patient-facing interactions, either in person or via phone.
Hybrid role, must be able to commute to Hyannis, MA weekly. Regular interaction with cross-functional teams including Quality, Population Health, Clinical Operations, and Finance.
Salary Range $70,000-78,000
The posted range represents the full earning potential for the role over time, not the typical starting or hiring rate. Starting pay is determined based on factors such as relevant experience, skills, internal equity, and market alignment. The top of the range reflects compensation that employees may reach through demonstrated performance, increased responsibilities, and tenure in the role. This structure allows us to support growth and advancement while maintaining fairness and consistency across the organization.
Job Type: Full-time
Pay: $70,000.00 - $78,000.00 per year
Benefits:
- Dental insurance
- Employee assistance program
- Flexible schedule
- Flexible spending account
- Health insurance
- Health savings account
- Life insurance
- Paid time off
- Retirement plan
- Vision insurance
Work Location: In person
