Minimum Education
High School Diploma or GED (Required)
Minimum Work Experience
5 years Related patient accounting experience required especially related to denial mitigation, root cause analysis and LOC reconciliation. (Required)
Functional Accountabilities
Pre-Billing
- Review inpatient cases before billing to ensure that leveling, authorization, eligibility and any other function to ensure a clean claim is released for billing.
- Continuously monitor the pending report with CRM to ensure issues are resolved in a timely manner.
- Maintain OP DNFB to include updating DX codes from PPM.
Analyze and Report
- Conduct root cause analysis of issues reducing reimbursement & slowing payment cycle; identify key issues and assist in tracking, trending and reporting; identify and clearly communicate deficiencies and resolutions of issues impacting reimbursement; respond in a timely fashion to any deviation from established and required processes and standards.
- Conduct analysis on a wide variety of issues related to billing, collections and denial processes; make process improvement recommendations based on findings; interact at all levels of CNMC to include senior management.
- Assist in development of solutions, training & education to resolve issues and share data with staff and management.
- Continuously work to improve the design and performance of the established reporting and tracking systems.
Appeal
- Ensure all high dollar denials & underpayments are appealed & followed up timely; ensure maximum recovery of reduced reimbursement.
- Manage large volumes of denials, denial amounts and various appeal deadlines to prioritize workload and maximize reimbursement.
- Process individual denials and ensure written appeals are clear, concise and within timely appeal limits.
Collection Support
- Check for payment posting and receive list of unpaid claims from system; proactively follow-up on submitted claims to determine payment status through telephone or web contact in a timely manner; collect information from carriers about what specific documentation is needed to pay claim.
- Contact internal departments (Health Information Management, Clinic Operations) for information and documentation to carrier to facilitate claim payment; provide documentation via fax, phone or mail to payer, e.g., operative reports.
- Track appeals of denied claims to determine status and work with carrier for payment; resubmit claim if payer does not have record of claim.
- Prioritize work to facilitate payment of higher account balances.
- May follow-up with parent, if insurance has paid parent to receive reimbursement.
- May recommend adjustments and write-offs to bill within identified parameters; refer to manager as appropriate.
Safety
- Speak up when team members appear to exhibit unsafe behavior or performance
- Continuously validate and verify information needed for decision making or documentation
- Stop in the face of uncertainty and takes time to resolve the situation
- Demonstrate accurate, clear and timely verbal and written communication
- Actively promote safety for patients, families, visitors and co-workers
- Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance
Organizational Accountabilities
Organizational Accountabilities (Staff)
Organizational Commitment/Identification
- Anticipate and responds to customer needs; follows up until needs are met
Teamwork/Communication
- Demonstrate collaborative and respectful behavior
- Partner with all team members to achieve goals
- Receptive to others' ideas and opinions
Performance Improvement/Problem-solving
- Contribute to a positive work environment
- Demonstrate flexibility and willingness to change
- Identify opportunities to improve clinical and administrative processes
- Make appropriate decisions, using sound judgment
Cost Management/Financial Responsibility
- Use resources efficiently
- Search for less costly ways of doing things
Safety
- Speak up when team members appear to exhibit unsafe behavior or performance
- Continuously validate and verify information needed for decision making or documentation
- Stop in the face of uncertainty and takes time to resolve the situation
- Demonstrate accurate, clear and timely verbal and written communication
- Actively promote safety for patients, families, visitors and co-workers
- Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance