Dedicated to the Health of the Community
The Health Care District of Palm Beach County is an integrated public health system established in 1988 as a special taxing district that is an equal opportunity employer of approximately 1 , 000 employees. The Health Care District's mission is to ensure access to a comprehensive health care system and the delivery of quality services for the residents of Palm Beach County. The Health Care District provides challenging and fulfilling employment opportunities through its health coverage programs for uninsured residents, a nationally recognized Trauma System, a School Health program which staffs registered nurses in nearly 170 public schools, a pharmacy operation, a long-term skilled nursing and rehabilitation center, and its acute care hospital, Lakeside Medical Center, in rural western Palm Beach County.
General Statement of Job
This position provides direction to the Overpayment and Recovery Analyst, the Provider Appeal Analyst, and the Administrative Specialists positions. It provides thorough investigation of provider claims and provider appeals for overpayment, incorrect provider coding and billing, incorrect payments and incorrect adjudication in accordance with the District’s and Healthy Palm Beaches’ benefit plans, provider contracts and District and Healthy Palm Beaches’ policies.. This position is responsible for ensuring providers are appropriately reimbursed for services rendered and for initiating and directing the recoupment of provider overpayments which are owed to the Health Care District and Healthy Palm Beaches. In addition, this position is responsible for the referral of potential fraud to the Risk Manager and appropriate departmental personal.
Specific Duties and Responsibilities
Provide leadership, direction and instruction to the team performing the function of appeals and overpayment review.
Analyze and identify trends for all Provider Appeals and overpayments.
Reviews provider appeals for the purpose of determining reversal or upholding of denial.
Monitor weekly appeal receipts and progress in resolution of appeals.
Monitor tracking of provider appeals and overpayments.
Monitor Appeals turnaround times to ensure prompt resolution requirements are met.
Collaborate with the Claims Processing Supervisor and the Claims Audit/Resolution Supervisor on trend and performance reports.
Maintains knowledge of District and Healthy Palm Beaches, Inc., policies and procedures.
Maintains knowledge of Medicaid prepaid health contract and other applicable contractual requirements including benefit plans for all lines of business.
Maintains current knowledge of all ICD-9, CPT-4 and HCPCS codes and their changes.
Maintain current knowledge of medical terminology, therapeutic and routine diagnostic tests.
Maintain knowledge of general billing procedures for health care providers and institutions.
Maintains current knowledge of Medicare and Medicaid reimbursement.
Generates and utilizes various reports for the investigation of all overpayments including incorrect billing and coding, NCCI edits, duplicate payments, incorrect payment adjudication, etc.
Conducts audits of the claims adjudication process
Participates in internal audits to evaluate proper reimbursement based on contractual requirements.
Responsible for the auditing of medical records to validate billed charges.
Independently responsible for the decision making regarding the recoupment of funds from providers.
Works closely with the System Analyst in the Information Technology Department, the Overpayment and Recovery Analyst and the Anti-Fraud Services vendor to ensure data is accurate, meets the required standards and troubleshoots data issues.
Audits and researches provider claims (hardcopy, scanned and EDI) and manages the recoupment and reversals.
Requests claims information and medical/surgical notes and reports from providers via letters and telephonic contact.
Analyses overpayment reports and medical/surgical notes to validate correct reimbursement.
Manages Pursuing and the recoupment of overpayments based on audit results and department guidelines.
Develop and maintain policies and procedures for the provider appeal process and the identification, investigation and recoupment process of overpayments.
Train staff on the identification, investigation and recoupment process.
Works with the Overpayment and Recovery Analyst to create letters to providers requesting recoupment of incorrect payment based on coding and medical record documentation.
Collaborates with the Claims Audit/Resolution Supervisor in the recoupment of funds from providers that do not voluntarily provide reimbursement.
Point of contact for providers who appeal or submit Requests for Reconsideration regarding the recoupment process and manages their appeal.
Documents each individual reimbursement review process, justification and conclusion.
Track and analyze trends in overpayment and recoupment.
Applies NCCI edits, along with Medicare and Medicaid billing guidelines.
Oversees and manages the generating of correspondence to providers regarding reimbursement issues.
Oversees the recoupment of overpayments including updating claims adjudication system.
Develop and maintain a system to document the flow of the process from initial identification of the codes in question, through the research, decision process, request for recoupment with adherence by provider or active recoupment, if required.
Maintain log of a overpayments/recoupment.
Referral of potential fraud, abuse or over-utilization to the Risk Manager.
Maintain and provide monthly log to senior management.
Refer reimbursement/system deficiencies to the Director of Reimbursement and Senior Director of Business Analytics.
Creates and utilizes process for ongoing monitoring of potential fraud and abuse issues.
Participates in internal workgroups as needed.
Emergency duty may be required of the incumbent that includes working in special needs or Red Cross shelters or to perform other emergency duties including, but not limited to, responses to threats or disasters, man-made or natural.
This job description reflects the general duties considered necessary to describe the principal functions of the job as identified and shall not be considered as a complete description of all the work requirements and expectations that may be inherent in the position. The omission of specific statements of duties does not exclude them from the position. Management of the Health Care District of Palm Beach County reserves the right to assign duties not listed herein as necessary to accomplish the goals of the organization.
High school diploma or GED required. Associate’s degree in health related field preferred.
Ten (10) years institutional and/or professional surgical coding experience preferably in a clinical or health insurance environment, to include a minimum of 2 years of supervisory or leadership experience in same field. Knowledge of medical terminology, medical insurance claims processing skills, coding of medical insurance claims including appropriate modifiers required. Extensive computer skills including Word, Excel and Outlook required. Must demonstrate analytical and organizational skills, time management skills, as well as excellent written/oral communication ability.
Professional Coder Certification required.
Valid Florida Driver’s License required. Current, valid State of Florida Registered Nurse license preferred.
The Health Care District is an Equal Employment Opportunity Employer and maintains a Drug Free Workplace. Qualified individuals with disabilities who require an accommodation to participate in the application process should contact Human Resources. Veterans preferred.
Health Care District of Palm Beach County - 2 years ago
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The Health Care District of Palm Beach County is an integrated public health system established in 1988 as a special taxing district that is...