Responsible for collections and/or refunds of highly complex cases. Performs functions necessary to facilitate payment recovery including research, appeals, and follow up. Identify trends, potential resolutions and escalate to manager. Provide data related to reimbursement reductions, overages, delays, and non-payment. Evaluate accuracy of contract modeling, communicate findings, and escalate as appropriate. Participate in payer meetings to resolve issues. Responsible for ensuring solutions implemented and goals achieved. Identify and monitor CMS & payor rule changes and work to ensure compliance.
Qualifications:
Minimum Education
Bachelor's Degree (Preferred)
Minimum Work Experience
5 years Related patient accounting experience required, especially related to denial mitigation and root cause analysis (Required)
Required Skills/Knowledge
Excellent working knowledge of complex contract reimbursement methodologies including transplant, global, APR DRGs among others.
Proven analytical skills including ability to make recommendations based on financial analyses.
Excellent PC skills including advanced skill proficiency in Access and Excel spreadsheet analysis.
Ability to work in a team environment with other analysts, managers, and department leaders.
Proficiency in presentation of analytical results.
Excellent working knowledge of coding & NCCI edits.
Demonstrated knowledge of managed care payer requirements in an acute hospital setting.
Demonstrated ability to facilitate team or group activities.
Excellent verbal and written communication skills.
Demonstrated ability to be flexible and to prioritize workload & decision-making skills.
Ability to analyze workflow for process improvement.
Strong organizational and coordination skills required.
Functional Accountabilities
Account Follow-up and Collections

• Ensure all assigned claims are followed up and/or appealed in a timely manner as per standard operating procedure (SOP); ensure maximum recovery of reimbursement.

• Follow up on all appeals to ensure receipt and processing by carrier and prevent loss to untimely appeal

• Evaluate contract management expected reimbursement and follow appropriate guidelines to report and escalate.

• Evaluate overpayments and process timely as per procedures

• Manage large volumes of line item denials, underpayments, and overpayments, and various appeal deadlines to prioritize workload and maximize reimbursement.

• Ensure written appeals are clear, concise and within timely appeal limits.

• Ensure appropriate supporting documentation is included with appeals.

• Analyze retracted payments to determine appropriate course of action to recover reimbursement.

• Prioritize work to facilitate payment of higher account balances.

Data Analysis and Issue Resolution

• Manage matrix of issues & resolutions including accountable stakeholders; ensure results and escalate issues as appropriate; regularly report updates and challenges to manager

• Conduct root cause analysis of issues reducing reimbursement & slowing payment cycle. Identify key issues and assist in tracking, trending and reporting.

• Present data and analysis clearly to all levels of staff and management.

• Meet with manager and outside departments to review issues and develop action plans.

• Assist in development of solutions, training & education guidelines to resolve issues and share data with staff and management.

• Appropriately engage and involve key accountable stakeholders in a collaborative manner.

• Research payer & CMS policies related to revenue cycle; identify & alert stakeholders of required changes; track and ensure completions.

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
Performance Improvement

• Understand managed care contracting & reimbursement schemes (Prof /Tech) as well as payer requirements, reimbursement policies & clinical policy bulletins and apply principles to improve performance.

• Apply CMS reimbursement rules to operation to drive improved performance.

• Develop knowledge of internal billing systems & edits and make recommendations to mitigate denials.

• Develop detailed knowledge of internal billing coding and CDM process to identify breakdowns and resolutions.

Organizational Commitment/Identification

• Partner in the mission and upholds the core principles of the organization

• Committed to diversity and recognizes value of cultural ethnic differences

• Demonstrate personal and professional integrity

• Maintain confidentiality at all times

Customer Service

• 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

Organizational Accountabilities (Staff)
Organizational Commitment/Identification
Teamwork/Communication
Performance Improvement/Problem-solving
Cost Management/Financial Responsibility
Safety