The work involves performing analysis to identify denials, appeals and corrective actions to maximize reimbursement for the Erie County Medical Center Corporation in compliance with payer regulations/guidelines including but not limited to Federal, State and local payers. The incumbent evaluates unresolved third party claims and reprocesses outstanding receivables. Work is performed under the direct supervision of the Denials Prevention Manager. Supervision is not a function of this position. Does related work as required.
TYPICAL WORK ACTIVITIES:
Monitors insurance denials on a daily basis; contacts insurance companies to resolve and recover denied claims;
Processes appeals with insurance companies to obtain proper reimbursement;
Tracks trends for denials and underpayments to facilitate process improvements; recommends quality and/or improvement initiatives;
Collaborates with other departments to resolve claim issues;
Documents claim actions taken within patient account/claims/denial systems;
Obtains and verifies preauthorization approval for outpatient procedures; ensures preauthorization numbers are documented in Meditech Bar Module;
Serves as a resource for problem solving issues for registration, demographic and insurance errors;
Assists in providing and reviewing denial reports for various hospital departments;
Assists in training new staff;
Ensures compliance with Health Information Portability and Accountability Act (HIPPA) regulations;
FULL PERFORMANCE KNOWLEDGE, SKILLS, ABILITIES AND PERSONAL CHARACTERISTICS: Thorough knowledge of medical terminology, diagnosis and CPT-4 coding; good knowledge of hospital services; good knowledge of payer authorization guidelines; good knowledge of business arithmetic and English; ability to read and interpret Local Coverage Determinations and Federal and State billing regulations; ability to utilize Microsoft Office and internal billing systems; ability to communicate effectively, both orally and in writing; ability to establish and maintain effective working relationships; ability to carry out oral and written instructions; ability to train others; good problem solving, research, analytical and troubleshooting skills; tact; courtesy; initiative; resourcefulness; physically capable of performing the essential functions of the position with or without reasonable accommodation.
A) Graduation from a regionally accredited or New York State registered college or university with an Associate’s Degree in Health, Public or Business Administration, Finance, Accounting or closely related field and one (1) year of experience in outpatient, inpatient, skilled nursing or ambulatory/clinic billing, and denial experience; or:
B) Graduation from high school or possession of a high school equivalency diploma and three (3) years of experience in outpatient, inpatient, skilled nursing or ambulatory/clinic billing and denial experience.
NOTE: Verifiable part-time and/or volunteer experience will be pro-rated toward meeting full-time experience requirements.
Erie County Medical Center - 12 months ago