JOB DESCRIPTON: Researches and analyzes denial data and coordinates denial recovery responsibilities. Follow denials worklist prioritization of invoices established by department policies and procedures with resolution. Follow-up with patients to obtain additional information if applicable. Researches, responds, and documents insurer and patient correspondence/inquiry notes regarding coverage, benefits, and reimbursement on patient invoices. Generate an appeal or reconsiderations based on the dispute reason and contract terms specific to the payer. Identifies, analyzes, validates and researches frequent root causes of denials and develops corrective action plans for resolution of denials. Performs retro reviews of denials, submits formal appeal letters and aggressively follows up with the payer in order to achieve optimal financial outcomes- Escalate exhausted efforts for resolution. Communicate all denial trends to direct supervisor/manager in order to positively affect the volume of denials. Works with the payors to understand specific reasons for denials and preventable measures available to prohibit future denials. Responsible for maintaining or managing time effectively to complete assignments within established time frames, optimize collections, and meet performance goals. Demonstrates knowledge of all equipment and systems/technology necessary to complete duties and responsibilities. Timely and appropriate response to phone calls, internal questions, and correspondence from various departments, outside agencies, and payers regarding information pertaining the resolution of denied claims. Organizes job functions and work assignments to effectively complete assignments within established time frames. Researches denials included in EOBs for resolution and files appropriately. Works collaboratively with physician offices, Patient Access, Utilization Review, HIM and facility clinicians to correct deficiencies in a timely manner. Meet and maintain established departmental performance metrics for production and quality. Performs other duties as assigned.
MINIMUM QUALIFICATIONS: High School diploma or equivalent. Must have 4 years of healthcare related experience consisting of collections, 3rd party billing & collections, denials management, and technical appeals. Knowledge of Medicare, Medicaid, and other contract payers (HMO, PPO) preferred. CPAR (Certified Patient Account Representative) and/or CPFC (Certified Patient Financial Counselor) preferred for positions in clinic/hospital setting. Typing skills with a minimum of 35 wpm and good communication skills. Strong verbal and written communication skills. Should be proficient in Microsoft Office, with heavy exposure to patient accounting software and applications. Must be familiar with payer regulatory policies, medical terminology, and payment and adjustment calculations. Work collaboratively with physician offices, Patient Access, Utilization Review, HIM and facility clinicians to correct deficiencies in a timely manner. Demonstration of conflict resolution and mediation skills. Decision making, problem solving skills, critical thinking and listening skills required. Must be able to adapt to competitive ever changing work environment.
PHYSICAL REQUIREMENTS: (MediumMax 25lbs): up to 25 lbs, 0-33% of the work day (occasionally); 11-25 lbs, 34-66% of the workday (frequently); 01-10 lbs, 67-100% of the workday (constantly); Lifting 25 lbs max; Carrying of objects up to 25 lbs; Occasional to frequent standing & walking, Occasional sitting, Close eye work (computers, typing, reading, writing), Physical demands may vary depending on assigned work area and work tasks. ENVIRONMENTAL REQUIREMENTS: Factors affecting environment conditions may vary depending on the assigned work area and tasks. Environmental exposures include, but are not limited to: Blood-borne pathogen exposure Bio-hazardous waste Chemicals/gases/fumes/vapors Communicable diseases Electrical shock , Floor Surfaces, Hot/Cold Temperatures, Indoor/Outdoor conditions, Latex, Lighting, Patient care/handling injuries, Radiation , Shift work, Travel may be required. Use of personal protective equipment, including respirators, environmental conditions may vary depending on assigned work area and work tasks.