Hospital Appeals-Billing Specialist | Memorial Health

Memorial Health•Marysville, OH

2d•Onsite

About The Position

This role is responsible for understanding and adhering to payer requirements based on hospital contracts and policies. The specialist will collaborate with various departments to ensure accurate information and medical documentation for appeals. They will also work with Billing Representatives to ensure timely submission of appeals and documentation for reimbursement, review denial types, confirm claim submission timeliness, and verify coding and dates for accuracy before appeal submission. The role involves maintaining claims appeal logs, tracking reimbursements, and serving as a liaison between Patient Financial Services and the Emergency Department SANE coordinator for accurate billing to the Ohio State Attorney General’s Office. Additionally, the specialist will prepare documentation for SANE claim submission and manage Medicare Short Stay claim billing according to CMS guidelines, tracking all accounts for accuracy and timeliness. They will also manage retro authorizations when CPT codes on claims do not match authorized codes.

Requirements

Proficient with Microsoft Word, Excel, and PowerPoint.
Knowledge of office practices and procedures.
Knowledge of medical terminology.
Ability to communicate effectively.

Nice To Haves

1 - 3 years of hospital billing & claim appeals and hospital reimbursement experience preferred.
Associate or bachelor’s degree preferred.
Knowledge of revenue cycle functions.
Registration experience.
Understanding of health insurance and government programs.
Understanding of billing processes.
Understanding of managed care contracts.
Understanding of coordination of benefits with ability to interpret explanation of benefits desired.
Knowledge of hospital third party billing requirements.
Knowledge of Current Procedural Terminology (CPT).
Knowledge of International Classification of Disease (ICD)-9, ICD-10 and modifiers.

Responsibilities

Understand payer requirements per hospital contracts and payer policies, ensuring adherence.
Knowledge of payer contracts specific to timely filing deadlines and retro-authorization timelines.
Collaborate with various departments 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.
Collect data and create appeals based on payer requirements.
Review denial type, payor authorization approval information documented on the account, and confirm timely claim submission as required by the payer.
Confirm coding, service admit and discharge dates, patient level of care, and patient status are correct prior to appeal submission.
Maintain claims appeal logs, tracking to ensure payor reimbursement based on payor contract terms and payer specific rules.
Serve 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.