RC Denial & Appeal Specialist Remote - Military Veterans

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  DEPARTMENT: 68221 - Business Office NCHHG


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  LOCATION: 1100 Immokalee Road, Naples, FL, 34110


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  WORK TYPE: Full Time


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  WORK SCHEDULE: 8 Hour Day

$16.80-19.49hr

ABOUT NCH

NCH is an independent, locally governed non-profit delivering premier comprehensive care. Our healthcare system is comprised of two hospitals, an alliance of 700+ physicians, and medical facilities in dozens of locations throughout Southwest Florida that offer nationally recognized, quality health care.

NCH is transforming into an Advanced Community Healthcare System(TM) and we're proud to: Provide higher acuity care and Centers of Excellence; Offer Graduate Medical Education and fellowships; Have endowed chairs; Conduct research and participate in national clinical trials; and partner with other health market leaders, like Hospital for Special Surgery, Encompass, and ProScan.

Join our mission to help everyone live a longer, happier, healthier life. We are committed to care and believe there's always more at NCH - for you and every person we serve together. Visit nchjobs.org to learn more.

JOB SUMMARY

This position will work with a variety of insurance payers to determine why a medical claim was denied and submit appeals or redeterminations as indicated by the payer. In addition, this position is responsible for determining why an aged claim has not been paid. The Revenue Cycle Denial & Appeal Specialist is responsible for high dollar accounts and complex denials including CCI conflicts, overpayment recoveries, and denials related to no authorization.

ESSENTIAL DUTIES AND RESPONSIBILITIES

- Other duties may be assigned.

• Works with a variety of insurance payers to take action on denied claims to ensure the claim is paid on the first follow-up call or appeal.

• Works independently to review the Electronic Medical Record to verify claims were billed with the appropriate provider, place of service, and date of service.

• Assists Revenue Cycle Denial & Appeal Lead with training of onboarding Revenue Cycle Denial & Appeal Specialists

• Works closely with the department's designated insurance representatives to escalate upheld denials.

• Acts as a "Subject Matter Expert" for all questions concerning assigned payers and attends related meetings with payers to address and resolve problems and to gather information in preparation for those meetings.

• Drafts comprehensive and effective appeal letters to overturn claim denials.

• Research payer policies and communicate findings as needed.

• Responsible for billing errors, claim edits, payer rejections, and follow up work queues.

• Maintains current knowledge of reimbursement methodology and contract language specific to assigned payers.

• Process claims through an electronic system correcting all errors prior to submission.

• Validate claims sent are received by Payer (Selected Clearinghouse).

• Enter all transactional comments into the system to ensure accurate account documentation.

• Meets performance goals as defined by senior management (ex: clean claim rate, days in A/R, and pre-A/R days, etc).

• Meets productivity and quality metrics daily/weekly.

• Maintains current knowledge of Centralized Billing office billing systems.

• Maintains current knowledge of billing forms and filing requirements.

• Maintains current knowledge of Federal, State, and managed care billing methodologies, rules, and regulations.

• Ensures confidentiality of all patient accounts by following HIPAA guidelines.

• Corresponds with third party payers, physician offices and/or patients to obtain information. Escalates problems and high dollar accounts to the Revenue Cycle Denial & Appeal Lead for guidance and support.

• Informs Revenue Cycle Denial & Appeal Lead of key issues on a timely basis communicating key observations, issues, payer policy changes, and denial trends.

• Maintains current knowledge of effective follow up and collection approaches.

• Maintains current knowledge of timely payment regulations and holds payers accountable. Escalates non-compliance to senior management.

• Works closely with Cash Posting and the Credits/Refunds Team to address payment discrepancies and overpayments.

• Handles billing corrections identified by Practice Managers or Revenue Cycle Managers.

• Works with the SBO to resolve patient inquiries received via email or work queues.

• Stays on top of correspondence received on patient accounts related to assignment.

• Utilizes coding resources (i.e., CPT/ICD-10 books) to understand procedures that are denied.

• Completes appropriate adjustment requests based on appeal denials or payer contracts. Participates in general or special assignments and other duties as assigned.

EDUCATION, EXPERIENCE AND QUALIFICATIONS

• Minimum High School Diploma or GED required.

• Minimum of 1-2 years' experience with one or more of the following: third party claims billing, insurance follow up, denials management, underpayments, managed care contracts, cash application, credit resolution, audit, claims processing and revenue cycle compliance in a hospital, physician's, medical service organizations or health system revenue cycle department is required.

• Must have working knowledge and experience interpreting third party payer rules to include coordination of benefits, interpreting policy benefits, interpret contracts, state and federal regulations, overturning denials and underpayments and payment methodologies and remain current on all industry changes in billing requirements.

• CPC credential from American Academy of Professional Coders (AAPC), CCA or CCS credential from American Health Information Management Association (AHIMA) preferred.

• Medical Terminology, Knowledge of ICD-10, HCPCS and CPT-4 codes required.

• Must have experience reading and interpreting insurance explanations of benefits.

• Organizational and time management skills required.

• Proficiency in computer keyboarding skills required.

• Ability to effectively gather and exchange information in both oral and written communications.

• Ability to use MS Office Suite (Word, Excel, Outlook) at an intermediate level.

• Ability to work independently with minimal supervision.

• Intermediate computer knowledge: Uses Microsoft Word, Excel, Outlook, and Windows.