Reviews and resolves accounts assigned via work lists daily as directed by management. Focus on working complex denials across multiple payers and/or regions. Conducts account history research as required, including navigating patient encounters and charts, researching charge and payment histories, determining historic account and claim status changes, and researching the payer remittance advice.
Conducts follow up research on claims to review contract discrepancy and account balances. This may include attaching documentation, amending coverage/patient/encounter/provider/facility data, gathering additional information requests, and resubmitting corrected claims to ensure accurate and timely claim adjudication. Review explanation of benefits (EOB) or, if not present, call the Payor to obtain claims status for denied claims
Defends and appeals denied claims, including researching underlying root cause, collecting required information or documents, adjusting the account as necessary, resubmitting claims, and all appropriate follow up activities thereafter to ensure adjudication of the claim. Must also be comfortable communicating denial root cause and resolution to leadership as needed.
Responsible for aggregating the data that is required and then sending complete appeal packets for every level of appeal either by mail, fax or Federal Express utilizing the denials management tool.
Identifies system loading discrepancies within the contract management system and refers to the Supervisor, Contract Manager or Contract Administrator for correction.
What You Will Need:
High school diploma or equivalent
1+ years’ experience in billing, A/R follow up and/or denials management & appeal writing
Basic understanding of an explanation of benefits (EOB)
Basic knowledge of CPT, ICD-10, and HCPCS coding standards
This position is responsible for analyzing payer account reconciliation discrepancies and identifying variance causes for the identification and resolution of payer denials and expected reimbursement underpayments. Responsible for recognizing payer trends to maximize expected reimbursement for the managed care contracts. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all. Under general supervision of the Supervisor of Denials Management, will be responsible for billing and A/R follow up, denial recovery, prevention and appeal writing activities while adhering to the rules and regulations of all government and Managed Care payers in meeting all audit and appeal responsibilities. Performs outgoing calls, corresponds with patients and insurance companies to obtain necessary information, amended or corrected claim resubmissions and communicates with other departments to ensure accurate and timely claim adjudication. This position will be responsible for activities requiring a deep insight into understanding of payer contracts. Adheres to AHS Compliance Plan and to all rules and regulations of all applicable local, state and federal agencies and accrediting bodies.
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.