Subject Matter Expert (SME) – Billing

North Florida Surgeons•Jacksonville, FL

21h•Hybrid

About The Position

The Billing Subject Matter Expert (SME) serves as the go-to resource for complex, specialty-specific billing across Orthopedics, General Surgery, Plastic Surgery, Vascular, Otolaryngology (ENT), and Ophthalmology . This role ensures accurate coding, compliant charge capture, clean claim submission, and timely resolution of denials. The SME partners with clinical, front office, surgery scheduling, ASC/HOPD, and finance teams to optimize reimbursement, minimize rework, and maintain regulatory compliance.

Requirements

High school diploma or equivalent required; Associate’s/Bachelor’s in Healthcare Administration, HIM, Business, or related field preferred.
CPC, COC, CPB, CCS-P, or CMOM strongly preferred; specialty credentials (e.g., COSC for orthopedics, COA/COT familiarity for ophthalmology) a plus.
3–5+ years in professional billing/coding; multi-specialty experience required with at least two of the target specialties .
Deep understanding of CPT/HCPCS, ICD-10-CM, global periods, modifiers, NCCI, MUEs, LCD/NCD, and payer medical policies (Medicare, Medicaid, commercial).
Proficiency with EHR/PM/claim scrubbers (e.g., Epic, athenahealth, NextGen, Cerner, eClinicalWorks, Availity, Change Healthcare ).
Advanced denial analytics, root-cause problem solving, provider education, clear written appeals, and cross-functional collaboration.
Regulatory & Payer Policy Mastery
Detail Orientation & Audit Rigor
Data Literacy (Excel/BI) & Trend Analysis
Communication & Training Delivery
Change Management & Process Design
Professional Judgment & Confidentiality (HIPAA)

Responsibilities

Expert Escalation Point: Lead resolution of complex coding, billing, and payer policy questions; guide staff on edits, bundling, and medical necessity.
Charge Review & Edits: Monitor WQs for CCI/NCCI edits, MUEs, and payer-specific rules; correct and educate to prevent recurrence.
Denials Management: Trend denials (CO-16, CO-97, CO-50, MUE, bundling, global conflicts, missing auth); implement corrective workflows and write appeal letters with supporting guidance.
Authorization & Eligibility: Oversee pre-cert workflows for surgeries, injections, imaging, DME, drugs (buy-and-bill); ensure benefits and financial clearance (ABN/Good Faith Estimate when applicable).
Documentation Integrity: Align clinical documentation with CPT/HCPCS and ICD-10-CM; drive provider education on specificity, laterality, time-based services, split/shared, and global periods.
Regulatory Compliance: Maintain adherence to Medicare/Medicaid, commercial payer policies, OIG guidance, LCD/NCD coverage criteria, and modifier usage.
Training & SOPs: Create job aids, quick-reference guides, and deliver staff/provider training for updates (CPT/ICD changes, payer policy changes).
Data & Process Improvement: Analyze KPIs (DNFB, first-pass yield, days to payment, denial rate by reason, AR > 90, write-offs, net collection rate) and lead improvement initiatives.
Systems Optimization: Partner with IT for EHR/PB (e.g., Epic, athenaIDX, Cerner, NextGen) configuration, charge router rules, claim scrubber edits, and fee schedule updates.
Orthopedics Global Surgical Package: Apply fracture care global rules (casting/splinting included/excluded), post-op modifiers -58/-78/-79 , staged/related procedures, return to OR.
Injections & Imaging: Bill joint injections (e.g., 20610/20611) with ultrasound guidance (76942) when documented; understand MUEs and bilateral/laterality modifiers ( RT/LT, -50 ).
DMEPOS: Manage braces/splints (L-codes/A-codes), proof of delivery, and CMNs where required.
Implants & Facility Coordination: Coordinate ASC/HOPD authorizations, implants, device credits, and carve-outs.
General Surgery Endoscopy & Procedures: Distinguish screening vs diagnostic colonoscopy (modifiers 33, PT as applicable); apply bundling/edit logic for laparoscopic vs open procedures.
Hernia & Soft Tissue: Know payer-specific documentation for hernia types, mesh use, re-do surgery, and post-op complications.
Trauma & Assistant Surgeons: Apply assistant surgeon modifiers ( -80/-81/-82 ), trauma activation when relevant, and global rules on staged operations.
Plastic Surgery (Reconstructive & Cosmetic) Medical Necessity & Photos: Manage reconstructive vs cosmetic determinations, pre-auths with photo documentation, and payer medical policies.
Complex Repairs & Flaps: Code layered closures, tissue rearrangements, flaps/grafts, breast reconstruction (timing and laterality).
Financial Consents: Enforce self-pay estimates, ABNs/financial waivers for non-covered cosmetic services, and dual billing (cosmetic + medical when appropriate).
ENT (Otolaryngology) Allergy Services: Bill allergy testing ( 95004/95024 ), serum prep ( 95165 ), and immunotherapy administration ( 95115/95117 ) per payer guidelines.
Audiology & Vestibular: Understand diagnostics (e.g., 92557, 92567, 92540 ), medical necessity, and supervision requirements.
Sinus/Otologic Procedures: Apply endoscopic sinus surgery coding, septoplasty, tympanostomy tube policies, and procedure bundling rules.
Ophthalmology E/M vs Eye Codes: Apply ophthalmic exam codes ( 92002–92014 ) vs E/M based on payer; understand incident-to and time/documentation requirements.
Imaging & Testing: Bill OCT (92133/92134), visual fields (92083), fundus photos (92250) with LCD-driven indications and frequency limits.
Drugs & Injections: Manage intravitreal injections (67028) with buy-and-bill J-codes (e.g., anti-VEGF), wastage reporting (JW/JZ), units, and serial treatment auths.