Patient Access Representative III - Hilton Head

Conifer Health Solutions • Hilton Head, SC

2d

About The Position

JOB SUMMARY Responsible for validating dispute reasons following Explanation of Benefits (EOB) review, escalating payment variance trends or issues to NIC management, and generating appeals for denied or underpaid claims. ESSENTIAL DUTIES AND RESPONSIBILITIES Include the following. Others may be assigned. Validate denial reasons and ensures coding in DCM is accurate and reflects the denial reasons. Coordinate with the Clinical Resource Center (CRC) for clinical consultations or account referrals when necessary, Generate an appeal based on the dispute reason and contract terms specific to the payor. This includes online reconsiderations. Follow specific payer guidelines for appeals submission Escalate exhausted appeal efforts for resolution Work payer projects as directed Research contract terms/interpretation and compile necessary supporting documentation for appeals, Terms & Conditions for Internet enabled Managed Care System (IMaCS) adjudication issues, and referral to refund unit on overpayments. Perform research and makes determination of corrective actions and takes appropriate steps to code the DCM system and route account appropriately. Escalate denial or payment variance trends to NIC leadership team for payor escalation. KNOWLEDGE, SKILLS, ABILITIES To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Intermediate understanding of Explanation of Benefits form (EOB), Managed Care Contracts, Contract Language and Federal and State Requirements Intermediate knowledge of hospital billing form requirements (UB-04) Intermediate understanding of ICD-9, HCPCS/CPT coding and medical terminology Intermediate Microsoft Office (Word, Excel) skills Advanced business letter writing skills to include correct use of grammar and punctuation. Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings. As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities, and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost, and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

Requirements

• Intermediate understanding of Explanation of Benefits form (EOB), Managed Care Contracts, Contract Language and Federal and State Requirements
• Intermediate knowledge of hospital billing form requirements (UB-04)
• Intermediate understanding of ICD-9, HCPCS/CPT coding and medical terminology
• Intermediate Microsoft Office (Word, Excel) skills
• Advanced business letter writing skills to include correct use of grammar and punctuation.
• High School Diploma or equivalent, some college coursework preferred
• 3 - 5 years experience in a hospital business environment performing billing and/or collections

Responsibilities

• Validate denial reasons and ensures coding in DCM is accurate and reflects the denial reasons.
• Coordinate with the Clinical Resource Center (CRC) for clinical consultations or account referrals when necessary
• Generate an appeal based on the dispute reason and contract terms specific to the payor. This includes online reconsiderations.
• Follow specific payer guidelines for appeals submission
• Escalate exhausted appeal efforts for resolution
• Work payer projects as directed
• Research contract terms/interpretation and compile necessary supporting documentation for appeals, Terms & Conditions for Internet enabled Managed Care System (IMaCS) adjudication issues, and referral to refund unit on overpayments.
• Perform research and makes determination of corrective actions and takes appropriate steps to code the DCM system and route account appropriately.
• Escalate denial or payment variance trends to NIC leadership team for payor escalation.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED
• Number of Employees: 5,001-10,000 employees