Job Description

Responsibilities

Hospital – Revenue Recovery Specialists Using evidence-based criteria, conducts medical necessity review, based upon denial root cause, to prepare the denial argument for all levels of appeals;

Prepare and present case studies with the respective source of denial (Case Management, Physicians, and payer);

Develops, maintains, and manages cases utilizing an internal software appropriate (i.e. denial/appeal summary, outpatient denial summary, and audit summary);

Identifies, monitors, and presents monthly denial performance accompanied by case studies and recommendations for process improvements;

Participates in external payer meetings, presenting payer performance related to denials;

Serves as the Subject Matter Expert (SME) for clinical denials documentation and payer clinical guidelines;

Consult with other disciplines and other ancillary departments (i.e. physician, coding, OR, cardiology, pharmacy, purchasing, case management, respiratory therapy, clinical documentation specialists, etc.) as needed to obtain necessary documentation to support the clinical appeal and implement prevention;

Works with departments throughout the organization, third-party vendors, and insurance carriers to resolve denials related to SEHA billing;

Works with all stakeholders when identifying trends that can lead to inappropriate denials;

Proactively identifies problems and opportunities for improvements related to system usage, training and end-user education, practice, and user trends and makes recommendations to the Manager of Revenue Recovery for resolution;

Assists in the development of reporting mechanisms to identify trends and track so that education can be performed to reduce and/or resolve high dollar/high volume claims;

Provides and promotes ideas geared toward process improvements within the Central Billing Office;

Independently works on the resolution of complex claims issues, denials, and appeals;

Enhances professional growth and development through in-service meetings, education programs, conferences, etc.;

Refers complex or sensitive issues to the attention of the Supervisor and Manager of Revenue Recovery to ensure corrective measures are taken in a timely fashion;

Accepts and learns new tasks as required and demonstrates a willingness to work where needed;

Assists other staff as required in the completion of daily tasks or special projects to support the department’s efficiency.

Qualifications

Qualification :-

Special Certificate:-

Required

• A minimum of (3) years of healthcare customer service, claims, denials, appeals, compliance, or related experience is required.
• Ability to communicate with multiple levels in the organization (e.g. managers, clinical, and support staff);
• Excellent organizational skills including effective time management, priority setting, and process improvement;
• Understands the difference in billing, collections, payments, and refunds from payors;
• Possess an understanding of accounts receivables and claim denials;
• Knowledgeable and/or previous experience in Recovery Audits and payor audit processes;
• Clear concise verbal and written communication skills;
• Computer experience in Microsoft Office (Word and Excel);
• Knowledge of general medical terminology, CPT, ICD-9, and ICD-10 coding.
• Extensive knowledge of healthcare revenue cycle systems;
• 4 years of experience in registration, billing, and denial prevention environment-related fields or front-end access-related fields;
• Strong knowledge of third-party payor reimbursement, eligibility verification process, and government and payor compliance rules