The person in this position will be responsible to monitor and research cases that are in-house and on the discharged not final billed report to mitigate any potential denials and ensure that claims are clean before billing. Individual will work closely with Clinical Resource Management (CRM) to ensure cases reflect the correct clinical level of care and ensure clinical information is received by the insurance carrier for timely level of care authorizations by the payers. Monitor and report payer authorization delays and stall tactics as they occur . Follow-up with all insurance carriers to facilitate timely and
correct reimbursement for high balance cases. Investigate and report reasons for non-payment and delays. Perform root cause analysis of the various trends identified. Write appeals to recover denied and underpaid claims. Support payer escalation process by being able to ensure high balance cases are prepared for outsourcing to attorney . Gather documentation and summarize issues for attorney .

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