GENERAL SUMMARY:

Responsible for monitoring payer denials, payment variances and ensuring system goals are maintained. Primary responsibilities of the position include identifying, appealing and monitoring payer denials, and collecting third party contractual underpayments. Analysis of the data, communication of findings and assisting in process improvement are all key components of this position.

PRINCIPAL JOB FUNCTIONS:

1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values.

2. *Deciphers various aspects of contract reimbursement and performs analysis on differences between expected and actual reimbursement.

3. *Prepares and analyzes reports used to oversee third party payer activity, compares and interprets data to determine root cause of denials and uses the data to complete the appropriate resolution and implement efficiencies in the billing process.

4. *Provides information regarding payment discrepancies to Patient Financial Services Director and to Finance Administration.

5. Participates in activities to identify and resolve patterns of incorrect payments by third party payers. Contacts and resolves incorrect payments with payers, including escalating unresolved issues and managing communication with payer representatives.

6. *Analyzes denials and follows up on identified discrepancies; works with other areas to resolve any patterns or issues including root cause of underpayments and denials.

7. *Advises department director or other managers throughout the Medical Center, the Revenue Integrity Liaisons, and alliance hospitals on regulatory changes which need to be addressed to optimize reimbursement or meet compliance.

8. *Acts as reimbursement advisor for Patient Financial Services; advises Revenue Integrity Liaisons and other medical center departments regarding managed care contracts and proper payments.

9. Responsible for completing appeals and payer audits, including participating in federal payer audits – RAC, MAC, CERT, and QIO.

10. Identifies contract management errors and works with internal departments to ensure correct reimbursement data is available.

11. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.

12. Participates in meetings, committees and department projects as assigned.

13. Performs other related projects and duties as assigned.

(Essential Job functions are marked with an asterisk “*”).

REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:

1. Knowledge of third party payer (Medicare, Medicaid, insurance) pre-admission, admission and discharge guidelines, including billing requirements.

2. Knowledge of third party requirements for appeal and reconsiderations.

3. Knowledge of billing and accounts receivable management, including CPT coding, ICD-10 coding, revenue coding, DRG coding, APC coding, and EAPG reimbursement methodologies.

4. Knowledge of regulatory agencies and corporate compliance requirements related to reimbursement.

5. Knowledge of computer hardware equipment and software applications relevant to work functions.

6. Knowledge of hospital managed care contracts, contract implementation standards and schedules.

7. Ability to analyze problems, identify needs and priorities and implement effective work strategies and process efficiencies.

8. Ability to collect, compare, sort and prioritize information to be used in analysis processes.

9. Ability to prioritize work demands and work with minimal supervision.

10. Ability to communicate effectively both verbally and in writing.

11. Ability to consistently meet predetermined deadlines.

12. Ability to establish and maintain effective working relationships with all levels of personnel, medical staff, ancillary departments and vendor representatives.

13. Ability to maintain confidentiality relevant to sensitive information.

14. Ability to maintain regular and punctual attendance.

EDUCATION AND EXPERIENCE:

High school diploma or equivalency required. Minimum of one (1) year college coursework in accounting, coding, insurance or related field required. Minimum of three (3) years insurance billing experience in a hospital or professional environment preferred.

PHYSICAL REQUIREMENTS:

(Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.)

(DOT) – Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.

Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Extended use to the hands in operation of keyboard. Extended visual contact with computer screen.