[Summary[: The Senior DME billing code compliance and appeals specialist will play a crucial role in ensuring that our DME product complies with the billing codes and regulations set by Medicare and all federally funded payers. (Government Services). The successful candidate will have a deep understanding of the DME supply industry and Medicare billing requirements including but not limited to: Medicare coverage policies, HCPC Level II Codes, Medicare billing guidelines, Medical documentation, Appeal process, Fraud and Abuse regulations, Communication with educating patients and providers, and being an expert in Compliance and auditing. Essential Duties and Responsibilities:*]{calibri=""}]{calibri=""}*

• Determine medical necessity requirements for all federally funded business, including supplies.
• Train internal staff (ISR) and field reps on medical necessity.
• Oversee medical necessity chart review for all federally funded orders and conduct re-training as necessary for Sales and internal staff (ISR), to ensure performance improvement.
• Submit claims to insurance companies, Medicaid, and Medicare following established guidelines.
• Stay up-to-date with the latest healthcare regulations, including changes in coding guidelines and compliance requirements.
• Coordinate appeals on all claim denials, communicating with CMS and other federally funded third party payors.
• Represent VQ in all commination to federally funded payors.
• Develop an appeals process for all federally funded appeals.
• Oversee audits and TPEs, coordinate with relevant departments (billing, ISR, sales, etc.) to ensure accurate and timely responses as well as implement necessary changes to policies and procedures for performance improvement.
• Prepare comprehensive and accurate case files, including gathering relevant medical records and legal documents, for presentation at ALJ hearings.
• Collaborate with legal counsel and healthcare providers to prepare compelling arguments and evidence for ALJ appeals.
• Communicate with healthcare providers, insurance companies, and patients regarding billing and coding inquiries.
• Conduct regular audits of billing and coding practices to identify errors and discrepancies.
• Implement quality assurance processes to minimize coding mistakes and optimize reimbursement rates.
• Collaborate with other departments such as finance, legal, and compliance to ensure alignment of billing practices with organizational policies.

Qualifications/Competency: **

• Analytical and Research Skills; The ability to analyze complex data and billing information including reviewing and auditing billing data to identify errors or discrepancies and implement corrective actions
• Regulatory Compliance Knowledge: Well versed in regulatory requirement sand guidelines related to DME billing including Medicare regulations
• Communications Skills: Effective communication is essential for interacting with a wide range of stakeholders, including healthcare providers, patients, and insurance companies
• Knowledge of Coding Standards: A deep understanding of various coding standards like HCPCS, ICD-10, and CPT codes is crucial. Adept at applying appropriate codes and ensuring that billing is accurate and compliant with federal and state regulations.
• Attention to Detail: Must have meticulous attention to detail to ensure that every piece of information is accurate and that all codes are appropriate.

Education/Experience:**

High school Diploma or GED required.

Associate's Degree preferred