Facility Appeals Denial Management Specialist

Responsibilities

• Must possess effective and efficient communication, computer, specifically Microsoft Products and phone skills.
• Responsible for the resolution of claims that could not be collected or resolved utilizing our standard collection processes.
• Completes any and all required actions to correct billing issues so that claims can be re-filed and processed correctly by the payor.
• Provides additional information to payors as requested to facilitate claim payment, including medical records, itemized billing, implant invoices, EOBs, and card copies.
• Analyzes payments and adjustments to ensure compliance with managed care contracts, timely payment proposals, out of network policies, government payors, commercial payors, and state workers compensation schedules.
• Understands medical coding and its relation to reimbursement.
• Maintains knowledge of and adheres to applicable rules, regulations, policies, laws, contracts, and guidelines that impact reimbursement and CBO operations.
• Stays informed of the latest developments, advancements, and trends in the field of medical collections, appeals, and denials by utilizing available resources such as online information, reading information provided by payors, and attending seminars/workshops as approved by management.
• Recognizes and addresses issues with payors on behalf of HPI and articulates the issue in the manner needed to resolve the claim, including formal appeal letters, phone contact to payors/auditors, and contact with other departments.
• Maintains a positive and professional relationship with physicians, facilities, co-workers, management, payors, and other HPI clients.
• Solves complex reimbursement issues where standard responses do not result in optimal reimbursement.
• Handles stressful situations, multi-tasks a variety of responsibilities, and works under strict timelines.
• Is proficient in all systems, programs, and processes associated with their current position within the CBO.
• Works effectively and cooperatively with supervisors, co-workers, and clients.
• Follows the directions of supervisors.
• Refrains from causing or contributing to disruption in the workplace.
• Maintains regular and reliable attendance.

Requirements

• Experience with understanding Managed Care, Commercial, Government, Medicaid, and Workers Compensation claim determinations.
• Experience with physician/facility billing, both office and surgical claims denials, and filing of appeals on behalf of providers/facilities.
• Able to analyze payer contracts and apply rules/reimbursement to claims, make determinations if claims are paid correctly, and write/file appeals, if needed.
• Able to identify payer trends and research resolutions.
• Coding and anatomy knowledge, medical record review, and understanding are a plus.
• Experience with NCCI Edits, bundling, and CPT/ICD-10 coding is a plus.
• High School Diploma or G.E.D. required.

What We Offer

• Medical, dental, vision, and prescription coverage
• Life and AD&D coverage
• Availability of short- and long-term disability
• Paid holidays and vacation
• Employee Assistance Program (EAP)
• Flexible financial benefits including FSAs, HSAs, and Daycare FSA
• 401(k) and access to retirement planning