Facility Appeals Denial Management Specialist

Responsibilities

• Must possess effective and efficient communication, computer, specifically Microsoft Products and phone skills.
• Must be able to obtain resolution of accounts assigned to the denial/appeals team whether that is collection of additional monies due, resolution of claim issues that resulted in a denial, filing an appropriate appeal and/or any other actions warranted.
• Responsible for completing any and all required actions to correct billing issues so that claims can be re-filed and processed correctly by the payor.
• Responsible for providing additional information to payors as requested to facilitate claim payment. This includes, but not limited to, medical records, itemized billing, implant invoices, EOBs and card copies.
• Must be able to analyze 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.
• Must have an understanding of medical coding and how it relates to reimbursement.
• Expected to maintain knowledge of and adhere to applicable rules, regulations, policies, laws, contracts and guidelines that impact reimbursement and CBO operations. Seeks advice and guidance as necessary to ensure proper understanding.
• Expected to stay informed of the latest developments, advancements and trends in the field of medical collections, appeals and denials by utilizing available resources such as on-line information, reading information provided by payors and attending seminars/workshops as approved by management.
• Must be able to recognize and address issues with payors on behalf of HPI and be able to articulate the issue in the manner needed to resolve the claim. This includes, but is not limited to, formal appeal letters, phone contact to payors/auditors and contact with other departments.
• Employee is expected to maintain a positive and professional relationship with physicians, facilities, co-workers, management, payors and other HPI clients.
• Must exercise independent judgment and be able to analyze and report repetitive denials, payor requirement changes and other instances that affect reimbursement or CBO operations to appropriate party.
• Must be able to solve complex [problematic] reimbursement issues where standard response would not result in optimal reimbursement.
• Must be able to handle stressful situations, multi-task a variety of responsibilities and work under strict timelines.
• Employee is expected to be proficient in all systems, programs and processes associated with their current position within the CBO.
• Effectively working and cooperating with supervisors, co-workers and clients.
• Following the directions of supervisors.
• Refraining from causing or contributing to disruption in the workplace.
• Regular and reliable attendance.
• Performs other duties as assigned.

Requirements

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