Hospital Appeals-Billing Specialist | Memorial Health

Memorial Health Ohio•Paris Township, OH

3d•Onsite

About The Position

This role involves understanding payer requirements based on hospital contracts and policies, ensuring adherence to all payer stipulations. The specialist will need knowledge of payer contracts, specifically regarding timely filing deadlines and retro-authorization timelines. Collaboration with various departments is key to confirm the accuracy of information for appeals, supported by medical documentation. The specialist will also work with Billing Representatives to ensure timely submission of appeals and/or additional documentation for reimbursement, collecting data and creating appeals according to payer requirements. The role includes reviewing denial types, payor authorization approval information, and confirming timely claim submission. Accuracy of coding, service admit and discharge dates, patient level of care, and patient status must be confirmed before appeal submission. Maintaining claims appeal logs and tracking them to ensure payor reimbursement based on contract terms and payer-specific rules is also a responsibility. Additionally, the specialist will serve as a liaison between Patient Financial Services and the Emergency Department SANE coordinator for accurate billing to the Ohio State Attorney General’s Office, preparing all necessary documentation for SANE claim submission. The role also involves managing and preparing all accounts for Medicare Short Stay claim billing according to CMS guidelines and tracking these accounts for accuracy and timeliness. Finally, the specialist will manage all retro authorizations when the CPT code on the claim does not match the authorized code with the payor, working through the 'Precert CPT not on Code Integration' work queue.

Requirements

1 - 3 years of hospital billing & claim appeals and hospital reimbursement experience preferred
Knowledge of revenue cycle functions
Registration experience
Understanding of health insurance and government programs
Billing processes
Managed care contracts
Coordination of benefits with ability to interpret explanation of benefits desired
Knowledge of hospital third party billing requirements
Current Procedural Terminology (CPT)
International Classification of Disease (ICD)-9
ICD-10 and modifiers
Knowledge of office practices and procedures
Medical terminology
Ability to communicate effectively
Proficient with Microsoft Word, Excel, and PowerPoint

Nice To Haves

associate or bachelor’s degree preferred

Responsibilities

Understands payer requirements per hospital contracts and payer policies, ensuring adherence to all payer requirements.
Knowledge of payer contracts specific to timely filing deadlines and retro-authorization timelines.
Collaborates with various departments throughout the organization to confirm all necessary information for the appeal is accurate and supported through medical documentation.
Collaborate with Billing Representatives to ensure appeals and/or additional documentation is provided timely for reimbursement, collecting data and creating appeal based on payer requirements.
Reviews denial type, payor authorization approval information documented on the account, confirms timely claim submission as required by the payer.
Confirms coding, service admit and discharge dates, patient level of care and patient status are correct prior to appeal submission.
Maintains claims appeal logs, tracking to ensure payor reimbursement based on payor contract terms and payer specific rules.
Serves as a liaison between Patient Financial Services and Emergency Department SANE coordinator to ensure billing is accurate and appropriate for claims submission to the Ohio State Attorney General’s Office.
Prepare all documentation for SANE claim submission.
Manage and prepare all accounts for Medicare Short Stay claim billing through the various stages of the billing process in accordance with CMS billing guidelines.
Track all Short Stay billing accounts, ensuring each step is accurate and timely.
Manage all retro authorizations when the Current Procedural Terminology (CPT) code on the claim does not match the code that was authorized with the payor; work queue Precert CPT not on Code Integration.