Located in the heart of the Coachella Valley, you have access to resort-style living and world-class amenities throughout Southern California.
Job Objective:
Researches and resolves claim denials, ADR requests and certs; submits and tracks appeals, notes trends and provides monthly reports. Responds to audit requests (including RAC) from payors and maintains a Library of Payer reference material regarding requirement for pre authorization, medical necessity and documentation requirements. Works with the Revenue Cycle stakeholders (e.g. Admitting, Coding, Provider Liaisons, etc.) to provide information related to denials and opportunities for process improvement.
Job Description:
Education:
Required: High school diploma, GED or higher level degree
Preferred: Associate's degree
Licensure/Certification:
Preferred: Certified coder or currently enrolled in a coding program
Experience:
Required: Three (3) years of hospital/professional billing experience with an emphasis in denied claims follow-up, appeals processing, managed care and/or Medicare/Medi-Cal reimbursement methodologies
Preferred: Patient accounting experience in a high-volume claims’ environment
Essential Responsibilities:
- Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.
- Manages denial inventory on a timely basis to promote payment and resolution of all accounts as instructed by management.
- Stays current on all payer requirements by reading bulletins, reviewing provider handbooks, accessing websites, etc.
- Participates and engages in training sessions to grow knowledge base pertaining to denials, revenue cycle, and/or payor trends.
- Contacts payors, performs timely follow-up through direct phone calls, provider claims websites, correspondence, appeals, etc.
- Performs manual calculations of expected reimbursement to validate payor adherence to contracts.
- Performs in depth account research to understand every aspect of claims billing and resulting denial.
- Creates and submits strong succinct appeals that result in revenue recovery for all types of denials including contract underpayments, payor error denials, etc.
- Identifies patterns, trends, and root-cause for denials; reports findings to management to facilitate process improvement and resolution, including compilation of bulk denial issues across high volume of accounts.
- Generates and creates reports in Epic as requested.
- Adheres to HIPAA standards while performing denials research/resolution.
Essential Skils:
- Knowledge of health care pricing and reimbursement methodologies, especially IPPS/OPPS
- Knowledge of health plan contracts, hospital revenue cycle functions and payor compliance
- Ability to identify denial issues and craft succinct payer appeal letters
- Ability to prioritize and coordinate workflow productivity with attention to detail
- Knowledge of LCD’s, NCCI, MUE edits, Commercial, PPO, HMO, POS, EPO, and Medicare Advantage claims, authorization and documentation requirements
- Knowledge of CPT, HCPCS and ICD-10 coding requirements with emphasis on modifiers and diagnosis association
- Proficient in Microsoft Office Suite (Word, Excel, Outlook, PowerPoint) and other relevant software applications
- Strong analytical skills
- Basic knowledge of CMS coverage requirements and types of Medicare coverage (Part A/Part B/Part C, etc.)
