US Medical Billing and Coding Expert

WHO WE ARE AND WHERE WE ARE We are a small US software company entering healthcare IT, building our first EMR (electronic medical record) product for outpatient clinics. We say that plainly because it is the honest headline of this posting: we are new to this domain, we are pre-launch with no clients yet, and what we bring is a team that builds software well and the discipline to learn the domain properly before we build. We are looking for the person who guides us through the billing phase. We are at the stage where the billing and charge capture module gets designed: the part of the system where a finished visit becomes diagnosis codes, procedure codes, modifiers, charges, and ultimately a clean claim. Before we commit engineering time, we want that design grounded in how real US clinics actually operate, not in how software people imagine they operate. We would rather pay an expert to correct us early than pay for the rework later. WHY THIS ROLE EXISTS We are hiring an expert in US medical billing and coding as a paid guide and advisor for this phase of the build. To be completely clear up front: this is a teaching and advisory engagement. You will not process claims for us. There is no production billing work. You will never see patient data of any kind; all discussion uses hypothetical or fully de-identified examples. What we are buying is the knowledge in your head: the real, messy, day-to-day workflow of coding and billing in US outpatient clinics, explained patiently to a technical team that knows software well and clinic operations only from the outside. WHAT YOU WILL DO IN THE FIRST ENGAGEMENT The first engagement is 5 to 10 hours of your time over roughly 2 to 3 weeks, structured like this: 1. A 30 minute paid intro call. We confirm fit, agree on the session plan, and answer your questions. 2. Two or three recorded video sessions of 60 to 90 minutes each. The detailed plan below describes three sessions; if we land on two, sessions B and C get combined. Screen sharing is welcome for anything you can legally show, such as blank superbill templates, encoder tools, or public payer fee schedules. Recordings are for our internal design reference only and will never be published or shared outside the product team. 3. Async written follow-ups. We will keep a shared document of follow-up questions as they come up during design work. We ask you to answer in writing, billed hourly. 4. One design review pass. We show you our draft billing screens and workflow diagrams and you tell us, bluntly, where they diverge from clinic reality. DETAILED SESSION PLAN Session A: From the encounter to the codes. How a visit actually turns into codes in your clinic. Who does what: front desk, medical assistant, provider, coder, biller, practice manager. Eligibility checks before the visit. How the provider documents, and whether the provider selects codes at the point of care or a coder abstracts them from the note afterward. How superbills and charge capture work in practice, paper and electronic. Favorites lists and specialty-specific code subsets. E/M leveling in the office setting (99202 to 99215) and how providers really pick the level. How modifiers get applied in real life: 25, 59 and the X subset, 24, 79, LT and RT, and the ones that cause the most trouble. Place of service codes. How specialties differ, to whatever extent you have seen (primary care, behavioral health, PT, specialty surgical, etc.). Session B: From the codes to the paid claim. Charge entry and charge review. Claim scrubbing: what edits fire before submission (NCCI pairs, medical necessity against LCD and NCD policies, payer-specific rules) and what tool runs them. How the 837P gets generated and which clearinghouse you use (Availity, Waystar, Trizetto, Optum, other) and what the clearinghouse rejects versus what the payer denies. What comes back: 835 ERA and EOBs, payment posting, adjustment codes (CARC and RARC) you see most. The denial workflow: the most common coding-related denial reasons, who works them, and how rework flows back to the coder or provider. Patient statements and balances. Where charge lag comes from and what makes a clean claim rate good or bad. Session C: Where the codes themselves come from and how they are maintained. This session matters a lot to us. We want the ground truth on sources: when you assign an ICD-10-CM, CPT, or HCPCS code, where does the list you are choosing from physically live? EHR or PM built-in code sets from the vendor? An encoder subscription such as AAPC Codify, Optum EncoderPro, or Find-A-Code? Code books on a desk? Payer fee schedules? Spreadsheet cheat sheets the clinic maintains? All of the above? How the annual update cycle reaches you in practice: ICD-10-CM on October 1, CPT on January 1, HCPCS quarterly. What actually happens in the clinic in the weeks around those dates: who updates the superbill and the favorites lists, what breaks, how claims spanning the cutover get handled, and what happens when a code you used all year is deleted or replaced. How payer fee schedules and RVU-based pricing enter the picture when charges are set. THE CONCRETE QUESTIONS WE NEED ANSWERED If you read only one section, read this one. These are the questions driving the engagement: 1. What process does your clinic follow, end to end, to get from a completed patient visit to a submitted claim? Who touches it at each step and in what system? 2. How do the people assigning codes obtain those codes day to day? Is the source a physical book, a website, an Excel sheet, a database inside the EHR, an encoder subscription, or some combination? 3. How feasible is it for a clinic to have, or to want, the complete code lists inside its EMR, and what does the clinic expect the EMR vendor to handle (including how you understand CPT licensing from the AMA to work in practice, versus ICD-10-CM and HCPCS which are public)? 4. What should a well-designed EMR billing module do for coders and billers that your current systems do badly? Where do you lose the most time? What causes the most preventable denials? 5. If you were advising a team building charge capture from scratch for outpatient clinics, what would you insist they get right, and what common vendor mistakes would you warn them away from? OUR CURRENT WORKING UNDERSTANDING (CORRECT US WHERE WE ARE WRONG) We have done our homework from public sources, but reading about billing is not the same as living it. So you can calibrate your teaching, here is our current mental model. Part of your job is to tell us where it is wrong or oversimplified: 1. In small and mid-size clinics, the provider often picks codes from a superbill or favorites list at the point of care, and a biller or coder reviews and corrects before charges go out. In larger or specialty settings, certified coders abstract codes from the note. 2. Clinics do not maintain full code catalogs themselves. The EHR or PM vendor ships licensed code sets, supplemented by encoder subscriptions and payer fee schedules. 3. ICD-10-CM and HCPCS Level II are public and free from CMS and CDC. CPT and its modifiers are AMA-owned and licensed, which is why EMR vendors pay royalties, and why clinics get CPT through their software rather than downloading it. 4. Claim scrubbing against NCCI edits and payer rules happens in some combination of the PM system and the clearinghouse before the payer ever sees the claim. 5. Most coding-related denials trace back to a handful of causes: medical necessity mismatches between ICD and CPT, missing or wrong modifiers, bundling edits, and eligibility problems that predate coding entirely. 6. The annual code updates are a recurring operational pain, mostly absorbed by the vendor plus a manual scramble to update superbills and favorites. If several of those made you wince, you are exactly who we want to talk to. DELIVERABLES - The recorded sessions themselves (internal use only). - Written answers in the shared question and answer document. - Margin notes or a marked-up review of our draft billing workflow designs. - Blank, non-proprietary artifacts are a bonus if you have them: a sample superbill template, a denial worklist structure, anything that shows the shape of the work without any real data. WHO WE ARE LOOKING FOR Required: - 3 or more years of hands-on coding and billing work in US outpatient clinics. Deep, real US clinic experience is the one thing we cannot compromise on. - CPC (AAPC) or CCS (AHIMA) certification strongly preferred; equivalent verifiable hands-on experience considered. - Daily working experience with at least one EHR or PM system such as Tebra (Kareo), athenahealth, eClinicalWorks, AdvancedMD, DrChrono, NextGen, or similar. - Able to explain clearly on camera, patient with beginner questions, and comfortable being recorded for internal use. Strong pluses: - CPB certification or hands-on billing (not just coding) responsibility. - Practice administrator or billing manager experience: you have owned the whole revenue cycle, not one seat in it. - Multi-specialty exposure. - Direct denials management ownership. - Prior consulting, training, or teaching experience of any kind. This engagement is essentially structured teaching. - Experience with more than one EHR, so you can compare how different vendors handle code selection and charge capture. - US-based, for the in-clinic perspective. WHAT THIS ROLE IS NOT - Not a medical billing services engagement. We are not outsourcing billing and there are no claims to work. - No PHI, ever. Do not share real patient information in any form during this engagement. Hypothetical and de-identified examples only. - Not credentialing, not AR cleanup, not a virtual assistant role. - Not a sales or referral role. LOGISTICS AND RATE - Hourly, 12 to 25 USD per hour, via a standard Upwork hourly contract. - If your rate is above this range but the engagement appeals to you, apply anyway and quote your real rate. For the right guide we will stretch. - 5 to 10 hours total for the first engagement, spread over 2 to 3 weeks at a pace that fits your schedule. - Sessions on Zoom or Google Meet, scheduled between 9am and 5pm US Central Time. - English. - All communication and payment stays on Upwork. AFTER THE FIRST ENGAGEMENT If the first engagement goes well there is a strong likelihood of ongoing advisory work while we build: recurring design reviews as screens get real, helping us design realistic denial and edge-case scenarios for testing, and sanity-checking claim outputs against what a clinic would expect to see. We are at the start of this product. The person who teaches us billing now has a standing seat at the table as it grows. HOW TO APPLY Start your proposal with the single word SUPERBILL so we know you actually read this posting. Generic copy-paste proposals will be declined without reply. Then answer these six questions directly in your proposal. Short, concrete answers beat long generic ones: 1. Which certifications do you hold (CPC, CPB, CCS, other) and how many years have you worked in US outpatient billing or coding? 2. Briefly walk us through how a claim gets from the provider signing the note to an 837P leaving the clearinghouse at your current or most recent clinic. Five sentences is plenty. 3. When do you use modifier 25 versus modifier 59? One or two sentences each. 4. Which EHR or PM systems have you used daily, and which encoder or code lookup tools? 5. Where do the code lists you work from actually come from in your clinic (vendor code sets, encoder subscription, books, spreadsheets)? 6. Have you taught, trained, or advised others before, in any setting? If yes, tell us about it in two or three sentences. OUR HIRING PROCESS We review proposals daily. Shortlisted candidates get a 30 minute paid intro call within a few days. We expect to hire quickly and start the first session within a week of hiring. If the answers to questions 2 and 3 in your proposal are solid, you are most of the way to the shortlist already. FREQUENTLY ASKED QUESTIONS Q: Is this ongoing billing work? A: No. It is a paid advisory engagement about how billing works, with likely ongoing advisory (not production) work afterward. Q: Will I need to prepare slides or materials? A: No. We will bring the questions and drive the agenda. Blank templates or public tools you can show on screen are welcome but not required. Q: Will you share my recordings? A: No. Recordings are internal design reference for the product team only. Q: Agency or solo? A: Solo individual experts strongly preferred. We want the person who did the work, not an account manager. Q: Do I need to be US-based? A: What we require is deep hands-on experience in US clinic billing. US-based is a plus for the in-room clinic perspective, but strong candidates with daily US billing experience will be considered wherever they live. Q: Why is the rate range modest? A: We are a small company at the start of our first EMR, and we have scoped this as a focused advisory engagement rather than a long contract. If your rate is higher, quote it and we will consider stretching for the right person.