Description

Location: SGMC Patient Financial Services
Department: PATIENT FINANCIAL SERVICES
Schedule: Full Time, 8 HR Day Shift,

SUMMARY:

The Denials Management Analyst is responsible for thorough understanding of existing and future managed care payment methodologies in order to effectively analyze zero paid, underpaid, overpaid and denied insurance claims and also make recommendations for continued revenue growth. The analyst is responsible for, timely and accurately, interpreting all payer contracts and regulations to determine the correct payer denied, bundled, and underpaid line items. Responsible for determining the optimal combination of rebilling, collections, and follow-up activities to ensure correct reimbursement. This includes coordination with payers, Patient Financial Services, Patient Access Services, Finance, Accounting and other departments as necessary. This position is responsible for timely and accurately reviewing and trending all payer contractual adjustment variances.

KNOWLEDGE, SKILLS & ABILITIES:

• Technical/system skills/knowledge: PC and Windows literacy required; prefer knowledge of, or experience with, EPIC HB Resolute and Microsoft Office applications.
• Extensive knowledge of insurance/managed care, to include: Medicare; Medicaid (Georgia and Florida); Medicaid CMO’s, Peach Care; Tricare (Standard, Extra and Prime); VA; Medicare Managed Care; Blue Cross (Georgia, Florida, out-of-state and FEP).
• Working knowledge of CPT-4, HCPCS, ICD-10, and DRG coding.
• Reimbursement methodologies: percent of charges; DRGs; discounted fee-for-service; fee schedule; cost-based; and per Diems.
• Must have a thorough understanding and knowledge of: patient type; financial class; insurance master; employer codes; admission source codes; relationship codes; accommodation, occurrence, value and condition codes.
• Related regulatory and legal requirements: Medicare Secondary Payer Questions; medical necessity; Medical Reviews and Appeals.
• Interacts with: patients; other departments; physician offices; acute medical care providers; insurance companies; employers; Medicare administrative contractors; utilization review companies; state regulatory agencies, GMCF, Medicaid.
• Knowledge of medical terminology.
• Strong verbal/written communication skills.
• Highly organized with the ability to prioritize work.
• College degree or coursework preferred.
• CPAR preferred.
• Types 40 wpm accurately.
• Clinical background beneficial.

WORKING CONDITIONS- ADA INFORMATION:

Modern, well lighted, air conditioned, general work area. Moderate noise level. Occasional overtime required. Ability to sit, stand or walk for moderate periods. Safe and efficient operation of office equipment including: copier, fax, printers, computer and telephone. Reading of printed materials, including physician orders. Listening and verbally responding to customers, staff, physicians and visitors. Moderately heavy lifting {0-25 lbs.}, reaching, stooping, pushing, pulling, bending, and twisting.