General Summary
Holds a pivotal position in ensuring hospitals receive accurate compensation for the services they provide by examining hospital claims to verify proper reimbursement and working with stakeholders to resolve issues and optimize reimbursement processes while adhering to regulatory guidelines and organizational policies.
Duties and Responsibilities
Remote Work Capable
Essential Functions:
- Serves as a subject matter expert with assigned payors to address Payer Variances and Denials.
- Investigates reasons for discrepancies, such as payment variances, coding errors, billing discrepancies, contract build or incorrect application of payer policies. Accesses external payer sites for payer policies, claim investigations, and claim disputes.
- Utilizes best practices along with technology enabled worklist and other internal tools to identify discrepancies between expected reimbursement and actual reimbursement amounts from insurance carriers.
- Provides trend analysis to management, leadership, and insurance liaison. Ensures timely recovery of underpayment and denials, while addressing any root causes that are contributing to incorrect payments.
- Prepares and submits correspondence such as letters, emails, faxes, online inquiries, appeals, adjustments and reports.
- Maintains thorough documentation, including root cause of underpayment or denial issues, trends, outcomes, and lessons learned to support ongoing improvement efforts and knowledge sharing within the organization.
- Actively participates in discussions, meetings, and brainstorming sessions where team members contribute insights and suggestions for improving processes.
- Provides input for contract renegotiations with the goal to streamline process, reduce variances and denials.
- Maintains the payer reference guides for assigned payers with known nuances, best practice processes for authorizations and appeals, and any current trends.
- Reviews dashboards and reports to monitor for root cause analysis, potential trends or patterns to reduce underpayments and denials.
- Corrects financial and demographic information that has been inaccurately entered into Epic.
- Assumes responsibility to lead projects as requested. May also lead process improvement initiatives for the department.
- Assists Team Lead with onboarding and training new staff, as requested.
Common Expectations:
- Maintains established policies and procedures, objectives, quality assessment and safety standards.
- Enhances professional growth and development through participation in educational programs, current literature, in-service meetings, and workshops.
- Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.
Qualifications
Minimum Education:
- High School Diploma or GED Required
- Bachelors Degree Preferred
Work Experience:
- 5 years Revenue Cycle experience Required
Licenses:
- Certified Revenue Cycle Specialist within 1 year Required or
- Certified Revenue Cycle Professional within 1 year Required or
- Certified Revenue Cycle Representative within 1 year Required or
- Certified Patient Accounts Manager within 1 year Required or
- Certified Healthcare Financial Professional within 1 year Required
Courses and Training:
- Business/Accounting, Finance or Management. Upon Hire Preferred
Knowledge, Skills, and Abilities:
- Excellent communication and interpersonal skills.
- Familiarity with ICD-10 and CPT codes.
- Strong knowledge of payer reimbursement rules, methodology and policies.
- Proficiency in healthcare billing systems (Epic preferred).
- Working knowledge of medical terms to help interpret edit resolution, claims remittance advice, medical record documentation and payer medical/payment policies.
- Ability to work independently, multitask, and prioritize in fast paced environment.
- Possess ability to work in a constantly changing environment, good judgment skills, and capable of making decisions with attention to detail.
- Strong analytical and problem-solving skills.
- Works effectively in a team environment.
- Proficient with Excel and Microsoft office.