What are the responsibilities and job description for the Managed Care Revenue Optimization Analyst: CORP - Mgd Care Rev Optim position at Memorial Healthcare System?
Summary:
Reviews and analyzes denials and short payments received from insurance plans to determine best plan for resolution.
Takes action required to obtain payment in accordance with the terms of payor contract, applicable billing guidelines and/or Federal and State laws.
Detailed
responsibilities:
• Reviews and analyzes managed care balances related to short payments, denials or those aged with no response.
Evaluates the authorization, coding, billing and correspondence to identify underlying issue and determine best course of action to be taken to collect.
Compiles detailed written appeal document outlining position for payment.
• Creates and maintains spreadsheets of open accounts.
Works directly with plan contacts to exchange data, identify root causes of issues and reconcile data to confirm resolution.
• Tracks outcomes of requests for payment to ensure timely identification of additional actions needed.
Reconciles and updates business system and reports with findings and formalizes appeal documents required for follow up action.
• Responsible for identifying and reporting to Management payment and denial trends for assigned payors.
• Interacts directly with Department Clinical Team as needed to obtain pertinent clinical facts needed to support medical necessity of services provided.
• Responsible to meet and maintain production and quality standards defined by department policies and procedures.
Competencies and skills:
Essential:
• STANDARDS OF BEHAVIOR: Acts in a manner that supports the standards of communication, respect, privacy, and teamwork by demonstrating a commitment to professional and ethical conduct.
• CUSTOMER SERVICE: Demonstrates commitment to service excellence by promptly addressing internal/external customer issues/requests, resolving concerns while maintaining a professional image and behavior to build and enhance the patient/family/customer experience.
• ACCOUNTABILITY: Accepts ownership of job roles and specific assignments/goals; works independently, takes responsibility for own actions; admits mistakes and judgment errors; and accepts constructive feedback.
Connects personal work results to the accomplishment of team and organizational goals.
• RESPONDING TO CHANGE: Accepts change and adapts in a positive and productive manner; handles unexpected situations and changes in direction calmly and with confidence.
Views new assignments and job responsibilities as an opportunity for growth.
• WORKLOAD MANAGEMENT: Manages completion of work assignments based on priority and due dates.
• MANAGED CARE COMPLIANCE APPEALS AND TRENDING: Analyzes, appeals, trends and resolves incorrect payments and denials of payments from non-governmental insurance carriers.
• ACCURACY: Completes work assignments within established quality and/or quantity standards.
• PROBLEM SOLVING: Ability to identify, analyze and effectively solve problems.
• TEAM WORK: Contributes to fullest potential to achieve team goals.
Education:
Essential:
• High School Diploma or Equivalent
Credentials:
Education equivalent experience:
Essential:
•
Other information:
Complexity of Work: Requires critical thinking and effective communication skills.
Must be able to demonstrate ability to make independent decisions.
Requires detailed knowledge of government and managed care insurance terminology and reimbursement methodologies.
Must have knowledge of federal and state regulations and laws/statutes related to payment for medical services.
Requires knowledge of proper billing and coding of hospital services.
Must be able to formulate and write formal business communications.
Intermediate knowledge of Microsoft Word and Excel.
Required Work Experience: Two (2) years experience working in a hospital/physician business office, managed care collections or managed care claims environment required.
Working conditions:
Essential:
• Bending and Stooping 40.00%
• Keyboard Entry 80.00%
• Lifting or Carrying 0 - 25 lbs Non-Patient 40.00%
• Pushing or Pulling 0 - 25 lbs Non-Patient 40.00%
• Repetitive Movement Hand/Arm 60.00%
• Sitting 60.00%
• Standing 60.00%
• Walking 60.00%
• Audible Speech 80.00%
• Hearing Acuity 80.00%
• Depth Perception 60.00%
• Distinguish Color 60.00%
• Seeing - Far 60.00%
• Seeing - Near 60.00%
• Dust 40.00%
• Computer Monitor 80.00%
Organizational Profile:
Memorial Healthcare System, consisting of 6 acute care hospitals, a nursing home, outpatient facilities, home health services and physician practices, provides quality, comprehensive care to the residents of the surrounding communities.
We invite you to join one of the nation's leading healthcare systems, recognized for use of advanced technology and clinical informatics.
Memorial Support Services provides a variety of business services to support our facilities.
The main offices are located in Miramar with satellite offices located throughout our system.
Disclaimer: This job description is not intended, nor should it be construed to be an exhaustive list of all responsibilities, skills, efforts or working conditions associated with the job.
It is intended to indicate the general nature and level of work performed by employees within this classification.
Reviews and analyzes denials and short payments received from insurance plans to determine best plan for resolution.
Takes action required to obtain payment in accordance with the terms of payor contract, applicable billing guidelines and/or Federal and State laws.
Detailed
responsibilities:
• Reviews and analyzes managed care balances related to short payments, denials or those aged with no response.
Evaluates the authorization, coding, billing and correspondence to identify underlying issue and determine best course of action to be taken to collect.
Compiles detailed written appeal document outlining position for payment.
• Creates and maintains spreadsheets of open accounts.
Works directly with plan contacts to exchange data, identify root causes of issues and reconcile data to confirm resolution.
• Tracks outcomes of requests for payment to ensure timely identification of additional actions needed.
Reconciles and updates business system and reports with findings and formalizes appeal documents required for follow up action.
• Responsible for identifying and reporting to Management payment and denial trends for assigned payors.
• Interacts directly with Department Clinical Team as needed to obtain pertinent clinical facts needed to support medical necessity of services provided.
• Responsible to meet and maintain production and quality standards defined by department policies and procedures.
Competencies and skills:
Essential:
• STANDARDS OF BEHAVIOR: Acts in a manner that supports the standards of communication, respect, privacy, and teamwork by demonstrating a commitment to professional and ethical conduct.
• CUSTOMER SERVICE: Demonstrates commitment to service excellence by promptly addressing internal/external customer issues/requests, resolving concerns while maintaining a professional image and behavior to build and enhance the patient/family/customer experience.
• ACCOUNTABILITY: Accepts ownership of job roles and specific assignments/goals; works independently, takes responsibility for own actions; admits mistakes and judgment errors; and accepts constructive feedback.
Connects personal work results to the accomplishment of team and organizational goals.
• RESPONDING TO CHANGE: Accepts change and adapts in a positive and productive manner; handles unexpected situations and changes in direction calmly and with confidence.
Views new assignments and job responsibilities as an opportunity for growth.
• WORKLOAD MANAGEMENT: Manages completion of work assignments based on priority and due dates.
• MANAGED CARE COMPLIANCE APPEALS AND TRENDING: Analyzes, appeals, trends and resolves incorrect payments and denials of payments from non-governmental insurance carriers.
• ACCURACY: Completes work assignments within established quality and/or quantity standards.
• PROBLEM SOLVING: Ability to identify, analyze and effectively solve problems.
• TEAM WORK: Contributes to fullest potential to achieve team goals.
Education:
Essential:
• High School Diploma or Equivalent
Credentials:
Education equivalent experience:
Essential:
•
Other information:
Complexity of Work: Requires critical thinking and effective communication skills.
Must be able to demonstrate ability to make independent decisions.
Requires detailed knowledge of government and managed care insurance terminology and reimbursement methodologies.
Must have knowledge of federal and state regulations and laws/statutes related to payment for medical services.
Requires knowledge of proper billing and coding of hospital services.
Must be able to formulate and write formal business communications.
Intermediate knowledge of Microsoft Word and Excel.
Required Work Experience: Two (2) years experience working in a hospital/physician business office, managed care collections or managed care claims environment required.
Working conditions:
Essential:
• Bending and Stooping 40.00%
• Keyboard Entry 80.00%
• Lifting or Carrying 0 - 25 lbs Non-Patient 40.00%
• Pushing or Pulling 0 - 25 lbs Non-Patient 40.00%
• Repetitive Movement Hand/Arm 60.00%
• Sitting 60.00%
• Standing 60.00%
• Walking 60.00%
• Audible Speech 80.00%
• Hearing Acuity 80.00%
• Depth Perception 60.00%
• Distinguish Color 60.00%
• Seeing - Far 60.00%
• Seeing - Near 60.00%
• Dust 40.00%
• Computer Monitor 80.00%
Organizational Profile:
Memorial Healthcare System, consisting of 6 acute care hospitals, a nursing home, outpatient facilities, home health services and physician practices, provides quality, comprehensive care to the residents of the surrounding communities.
We invite you to join one of the nation's leading healthcare systems, recognized for use of advanced technology and clinical informatics.
Memorial Support Services provides a variety of business services to support our facilities.
The main offices are located in Miramar with satellite offices located throughout our system.
Disclaimer: This job description is not intended, nor should it be construed to be an exhaustive list of all responsibilities, skills, efforts or working conditions associated with the job.
It is intended to indicate the general nature and level of work performed by employees within this classification.
Location/Region: Miramar, Florida
DIR MGD CARE CONTRACTING
Covenant Health -
Knoxville, TN
Revenue Optimization Analyst
White Lodging - White Lodging Services Corp -
Merrillville, IN
Managed Care Contracting
Assured Managed Care -
Chicago, IL
