Facility Appeals Denial Management Specialist

United Surgical Partners International Inc (USPI)•Oklahoma City, OK

1d•Onsite

About The Position

North Oklahoma City billing office looking for an organized, self-motivated, results oriented individual to fill an Appeals Denial Management Specialist position. The Appeals/Denial Management Specialist performs daily activities associated with the timely collection and resolution of accounts receivable. This employee is responsible for the resolution of claims that could not be collected or resolved utilizing our standard collection processes. Responsibilities include, but are not limited to, claim denials, underpayments, coding denials, filing of appeals, zero payments and other claim issues that result in incorrect reimbursement towards outstanding claims.

Requirements

Effective and efficient communication skills.
Effective and efficient computer skills, specifically Microsoft Products.
Effective and efficient phone skills.
Experience with understanding Managed Care, Commercial, Government, Medicaid, and Workers Compensation claim determinations.
Experience with physician/facility billing for both office and surgical claims denials.
Experience filing appeals on behalf of a provider/facility.
Ability to analyze a payer contract and apply rules/reimbursement to a claim.
Ability to make a determination if a claim is paid correctly.
Ability to write and file an appeal.
Ability to identify payer trends and research resolutions.
High School Diploma or G.E.D. required.

Nice To Haves

Coding and anatomy knowledge.
Medical record review and understanding.
Experience with NCCI Edits, bundling, and CPT/ICD-10 coding.

Responsibilities

Performs daily activities associated with the timely collection and resolution of accounts receivable.
Resolves claims that could not be collected or resolved utilizing standard collection processes.
Handles claim denials, underpayments, coding denials, filing of appeals, zero payments, and other claim issues that result in incorrect reimbursement.
Obtains resolution of accounts assigned to the denial/appeals team, which may include collection of additional monies due, resolution of claim issues, filing an appropriate appeal, or other warranted actions.
Completes required actions to correct billing issues so that claims can be re-filed and processed correctly by the payor.
Provides additional information to payors as requested, such as medical records, itemized billing, implant invoices, EOBs, and card copies.
Analyzes payments and adjustments to ensure compliance with managed care contracts, timely payment proposals, out-of-network policies, government payors, commercial payors, and state workers' compensation schedules.
Maintains knowledge of and adheres to applicable rules, regulations, policies, laws, contracts, and guidelines impacting reimbursement and CBO operations.
Stays informed of the latest developments in medical collections, appeals, and denials.
Recognizes and addresses issues with payors on behalf of HPI and articulates the issue to resolve the claim, including formal appeal letters, phone contact, and contact with other departments.
Maintains a positive and professional relationship with physicians, facilities, co-workers, management, payors, and other HPI clients.
Exercises independent judgment and analyzes and reports repetitive denials, payor requirement changes, and other instances affecting reimbursement or CBO operations to the appropriate party.
Solves complex problematic reimbursement issues where standard responses would not result in optimal reimbursement.
Handles stressful situations, multi-tasks a variety of responsibilities, and works under strict timelines.
Proficiently uses all systems, programs, and processes associated with their current position within the CBO.
Works and cooperates effectively with supervisors, co-workers, and clients.
Follows the directions of supervisors.
Refrains from causing or contributing to disruption in the workplace.
Maintains regular and reliable attendance.
Performs other duties as assigned.
Performs insurance and third-party payor collections for denied accounts or accounts with lower-than-expected reimbursement.
Resolves all denied claims assigned.
Reviews EOBs/correspondence to determine denial reasons and appropriate resolution actions.
Contacts third-party payors following established CBO guidelines.
Corrects billing issues and re-files corrected claims.
Researches, prepares, and files written formal appeals with appropriate attachments.
Contacts payors by phone to request corrected processing, additional information, audits, or medical reviews.
Completes information requests from payors for records and other billing documentation.
Routinely analyzes payment details and correspondence to verify correct claim processing by payors.
Moves account balances from insurance to patient responsibility when appropriate.
Submits applicable adjustments and ensures account balance accuracy.
Contacts offices, facilities, and other departments as required to resolve assigned accounts.
Responds to client requests within 1 business day or communicates expected turnaround time.
Familiarizes with each assigned client and their special handling requirements.
Works assigned accounts to completion daily according to established productivity standards.
Recognizes and reports payor trends or issues to management and/or co-workers.
Ensures all required logs/reports for denial tracking are accurate and completed daily.
Performs appropriate follow-up with insurance payors on previously submitted appeals until a determination is received.
Files second/third level appeals if the initial appeal is denied, incorporating additional information.
Reviews all final denials with team lead or manager and receives approval for resolving the account with appropriate adjustment.
Notes clearly and precisely all actions taken on an account in the system.