Job Category:

Revenue Cycle

Work Shift/Schedule:

8 Hr Evening - Morning

Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

About the Role:

Job Summary

Ensures correct identification and root cause of payer denials.  Initiate comprehensive appeal process to include contacting insurance companies to justify and resolve denials, as well as arranging for correct payment recovery. Works closely with the department manager on trending and reducing denials. Communicates appropriately to "Source Department" of denials to educate and troubleshoot.
 

Minimum Job Qualifications

• Licensure or other certifications:

• Educational Requirements: High School Diploma or GED

• Minimum Experience: Three or more years of medical experience including any of the following: insurance, follow-up, verifications, collections, triaging, coordinator or scheduling experience.

• Other:

Preferred Job Qualifications

• Preferred Licensure or other certifications:

• Preferred Educational Requirements: Associates Degree.

• Preferred Experience:

• Other:

Job Specific and Unique Knowledge, Skills and Abilities

• Working knowledge of managed care contracts, HCPCS, DRG and other billing and reimbursement methodologies

• Understanding of ANSI claim adjustment reason codes and ANSI remittance advice remark codes

• Ability to display a positive attitude

• Excellent analytical, communication and negotiation skills  

• Expert knowledge of UBO4 and EOB experience, knowledge with calculating expected reimbursement for hospital claims

• Extensive understanding of Managed Care reimbursement methodology with the ability to analyze Managed Care Contracts

• Expert knowledge of the patient accounting system, knowledge in Managed Care and billing practices revenue codes and CDM Codes

• Ability to work a denial through the life cycle of the appeals process timely and efficiently  

• Ability to work independently and as part of a cohesive team 

• Ability to complete multiple activities utilizing multiple applications efficiently and professionally  

Essential Tasks and Responsibilities

• Evaluates MedAssets Contract Manager expected reimbursement calculation to final payer payment to avert risk of net revenue loss to Northeast Georgia Medical Center (NGMC). Acts as subject matter expert for multiple, complex payer contracts to fully understand all scenarios of reimbursement due to NGMC. Manages a working inventory of identified payment discrepancies and denials for payment resolution. Analyzes payer denials and provide appropriate feedback to department manager when trends are identified. Identifies and corrects internal issues, such as incorrect revenue codes billed, to maximize potential net revenue reimbursement.

  Serves as payer liaison between the variance collections department and other departments, such as managed care and patient financial services.

• Pursues additional net revenue due to NGMC as a result of denied claims. Determines appropriate accounts to appeal for additional monies lost due to denials/underpayments. Prepares and submits correspondence, such as letters, emails, fax, and online inquiries to fully and comprehensibly explain reasons for appeal. Documents results of appeal process to accurately reflect reasons NGMC did not recover revenue, keeping in mind that documentation may be utilized in future legal actions.

• Reports contract compliance to appropriate parties, both internally and externally, as required. Follows up and escalates issues to upper management, such as payer non-compliance, to ensure managed care is constantly aware of payer contract compliance. Analyzes payment recoveries through root-cause analysis and report findings to department manager on a weekly basis. Attends payer meetings to present problem accounts requiring second and third level appeals to upper levels of payer management for payment resolution.

• Collaborates on special projects to ensure appropriate contract compliance and assist with revenue cycle operations as needed. Manages special projects, as the needs present, to resolve compound reimbursement issues that may affect hundreds of accounts. Works in partnership with areas such as patient financial services, managed care, and revenue man