Appeals Analyst Team Lead Full Time

Position Goal: 

Utilize coding certification knowledge and reimbursement methodology experience to monitor compliance; analyzing and pursuing appeal opportunities with payers and reporting appeals performance.  Perform claim audits to ensure billing compliance with coding rules and guidelines as well as payer-specific policies and conducts research initiatives to support overall billing and documentation compliance on an enterprise basis.

Position Responsibilities:

• Implements processes for identifying under-allowed claims using Contract Compliance tools and other available tools.
• Leverages coding knowledge to focus specifically on surgical/procedure based claims and medical necessity denials to identify appeal opportunities.
• Trends surgical claim billing errors by payer, provider, etc, to identify gaps in training and develop educational materials.
• Analyzes zero pay reports with special attention to surgical/procedure claims to evaluate billing accuracy regarding the correct use of ICD-10, CPT, HCPCs coding.
• Verifies applicable contract by, as dictated by operational procedures: reviewing EOB messages, reviewing patient ID card, verifying member information for managed care plans.
• Uses feedback and experience to refine communication skills and tools for use in preparing written, online, fax and telephone appeals.
•  Works with other analysts to develop appropriate and relevant appeal templates.
• Uses  Contract Compliance application  to track appeals and recoveries by all appeal staff.
• Establishes and cultivates helpful and effective contacts in offices.
• Implements escalation tracks with staff and is the point of contract for such.
• Establishes, trains and implements follow-up protocol with payers and networks by the appeals staff.
• Monitors and tracks payer contract issues, fee schedule compliance billing, registration, and posting errors, and provide continuous feedback to the Leadership.
• Collaborates with the Chief Compliance and Revenue Integrity Officer to identify revenue cycle education and training opportunities and to develop periodic and recurring training materials (newsletters, bulletins, etc.)
• Assists, as needed, with special projects regarding provider payer compliance and other revenue cycle compliance initiatives as identified by the Chief Compliance and Revenue Integrity Officer.
• Acts as an escalation point for the appeals team on possible appeal opportunities by analyzing medical coding compliance and billing information for accuracy, suspicious activity and compliance with healthcare regulation.
• Provides Leadership with monthly reports on appeals, recoveries, education needs and other revenue integrity opportunities.
• Actively reviews payer bulletins, memos, etc. to analyze potential impacts to billing procedures and reimbursement methodologies and builds a repository of updates for dissemination to key stakeholders.
• Communicates new payer rules or clinical guidelines to staff as well as Leadership.