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.
• Establishes meetings with appeals staff  to discuss ongoing trends and opportunities for revenue optimization.
• Establishes metrics for appeals staff and monitors accordingly.
• Cross-trains and performs appeals analysis within Hospital and Ambulatory Surgery Center claims, as needed.
• Maintains the strict confidentiality required for medical records and other data.
• Participates in professional development efforts to ensure currency in managed care reimbursement trends.

Experience:

Required:

• Five years with insurance claims/related experience, CPT and ICD-10 terminology experience
• Three years of above described experience with a Associates degree or higher in related field

Education:

Required:

• High school diploma or equivalent

Preferred:

• Associates degree or higher

Special Qualifications

 Required:

• Annual MVR may be required per policy and procedure; background reports may be ran as needed throughout the course of employment.
• Up-to-date coding certification; either CPC or coding credentials via AHIMA.
• Knowledge and PC skills, with proficiency in utilizing Microsoft office products (Word, Excel, Outlook, PowerPoint, etc.)
• Knowledge of medical terminology.
• Demonstrated skill in written and oral communication with colleagues, supervisors, and payer/network personnel.
• Demonstrated skill working in a team-oriented structure to achieve goals.
• Must be able to work independently.

Special Qualifications

Preferred:

• Experience conducting revenue cycle / billing related audits
• Knowledge of networks, IPAs, MSOs, HMOs, PCP and contract affiliations.
• Knowledge of the health care professional services billing (physicians and related health care professionals) and reimbursement environment.
• Knowledge of major types of practice management system (PMS) and EOB imaging systems. 
• Knowledge of managed care contracts and compliance.
• Demonstrated skill in gathering and reporting claims information.

 The Hughston Clinic, The Hughston Foundation, The Hughston Surgical Center, Hughston Clinic Orthopaedics, Hughston Medical, Hughston Orthopaedics Trauma, Hughston Orthopaedics Southeast and Jack Hughston Memorial Hospital participate in E-Verify. This company is an equal opportunity employer that recruits and hires qualified candidates without regard to race, religion, color, sex, sexual orientation, gender identity, age, national origin, ancestry, citizenship, disability, or veteran status.