Purpose of Job
- Responsible for review of denials for commercial / government, physician / facility and escalation of appeals to the payers as needed to obtain the maximum reimbursement in compliance to payer contracts and CMS regulations.
Job Requirements
- Education
  - High School Diploma or General Educational Development (G.E.D.) required.
  - College coursework in accounting and or health care preferred.
- Experience
  - Minimum 1-2 years experience working for a 3rd party payer or health care provider required.
  - Minimum 1 year of insurance billing experience preferred.
  - Six months Institutional and Professional ICD and CPT coding preferred.
  - Six months experience with DRG reimbursement and outpatient including ASC grouper, ER and outpatient reimbursement preferred.
  - Experience in researching Institutional and Professional claims to determine correct contract reimbursement using payer contracts preferred.
- License/Certifications
  - N/A
- Skills/Knowledge/Abilities
  - Skill using Microsoft Office, including Word, Excel, and Outlook.
  - Skill performing 10 key data entry.
  - Skill with verbal and written communication.
  - Knowledge of medical terminology.
  - Knowledge of patient accounting software and payer websites.
  - Knowledge of Universal Billing (UB) and Healthcare Financing Administration (HCFA) billing formats.
  - Knowledge of International Classification of Disease (ICD), Current Procedural Terminology (CPT), Revenue Codes, understanding of DRG methodology.
  - Knowledge of facility contracting rates.
  - Knowledge of CMS (Center for Medicare and Medicaid Services).
  - Knowledge of WPS ANSI remark codes.
  - Ability to maintain confidentiality.
  - Ability to read and understand payer explanation of benefits (EOB).
  - Ability to use basic accounting and math principles.
  - Ability to identify, trend and analyze data.
  - Ability to learn new software programs.
  - Ability to organize and prioritize work.
  - Ability to work independently.
  - Ability to identify and trend issues to improve or streamline processes.
  - Ability to maintain a professional demeanor with internal and external contacts.
Physical Requirements
- Weight Demands
  - Light Work - Exerting up to 20 pounds of force.
- Physical Activity
  - Occasionally Performed (1%-33%):
    - Balancing
    - Climbing
    - Carrying
    - Crawling
    - Crouching
    - Distinguish colors
    - Kneeling
    - Lifting
    - Pulling/Pushing
    - Reaching
    - Standing
    - Stooping/bending
    - Twisting
    - Walking
  - Frequently Performed (34%-66%):
    - Hearing
    - Repetitive Motions
    - Seeing/Visual
    - Speaking/talking
  - Constantly Performed (67%-100%):
    - Fingering/Touching
    - Grasping
    - Keyboarding/typing
    - Sitting
- Job Hazards
  - Not Related:
    - Biological agents (primary air born and blood born viruses) (Jobs with Patient contact) (BBF)
    - Physical hazards (noise, temperature, lighting, wet floors, outdoors, sharps) (more than ordinary office environment)
    - Equipment/Machinery/Tools
    - Explosives (pressurized gas)
    - Electrical Shock/Static
    - Radiation Alpha, Beta and Gamma (particles such as X-ray, Cat Scan, Gamma Knife, etc)
    - Radiation Non-Ionizing (Ultraviolet, visible light, infrared and microwaves that causes injuries to tissue or thermal or photochemical means)
  - Rare (1-33%):
    - Chemical agents (Toxic, Corrosive, Flammable, Latex)
    - Mechanical moving parts/vibrations
  - Note: Safety Officer can assist with identification of job hazards
Essential Job Functions
- Essential Functions I
  - Analyze denials compared to the applicable contract agreements, payer medical policy language, NMHS coding and authorization processes.
    - Analyze payments to ensure accuracy and initiate corrective action with third party payers.
    - Demonstrates understanding of contract and reimbursement language.
    - Maintain a follow up and reporting system to ensure receipt of reimbursement.
  - Analyze and research contractual and reimbursement issues and answers inquiries from internal and external sources.
    - Correct handling of denial.
    - Resolve denial in RCA according to department policy.
    - Timely follow-up of denials, appeals, etc.
  - Assist staff with work volume as needed.
    - Respond to special requests with accurate information.
    - Provide contract/payor recommendations.
  - Participate in payer meetings and escalates payer issues.
    - Assist with tracking payer agenda issues.
  - Provide training on contracts and reimbursement to other areas as needed.
- Essential Functions II
  - Participates in mandatory in-services and/or CE programs as mandated by policies and procedures/external agencies and as directed by management.
  - Follows and understands the mission, vision, core values, Employee Standards of Behavior and company policies/procedures.
  - Other duties as assigned.