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Form of workPosition Summary
Primarily responsible for thorough review of medical records and other medical documentation to determine appropriate billable services for hospital to construct an appeal for payment based on medical necessity or payer specific guidelines or criteria. Responsible for providing clients trending, revenue cycle fail point analysis, and best practice remediation recommendations.
Essential Duties and Responsibilities
- Build strong, lasting relationships with clients, payors and Revecore personnel
- Analyze medical records or other medical documentation to validate services, tests, supplies and drugs performed for accuracy related to billing for services rendered
- Ability to identify and interpret medical, radiological, laboratory or other tests and procedures as well as pharmaceutical drugs
- Ability to review and understand managed care contracts, hospital billing statements/bills and insurance denials
- Research commercial and governmental payor policies, clinical abstracts and studies, and other documentation related to claims payment to evaluate and appeal denied claims.
- Highly proficient with Interqual and MCG guidelines and demonstrate appropriate application to claim appeal argument.
- Understanding of patient accounting documents – UB04, EOB
- Perform research regarding denials and effectively communicate information to associates, colleagues, managers and clients
- Contact insurance company to obtain missing information, explain and resolve underpayments and/or denials and arrange for payment or adjustment processing on behalf of client
- Prepare and submit correspondence such as letters, emails, online inquiries, appeals, adjustments, reports and payment posting
- Perform denial trending for clients, identify fail points within the revenue cycle and on the payer side, and provide best practice recommendations to clients and Revecore managers.
- Maintain regular contact with necessary parties regarding claims status including payors, clients, managers, and other Revecore personnel
- Maintain confidentiality of information in compliance with company policy and HIPAA
- Attend client, department and company meetings
- Lead client meetings and perform consulting services to client’s as it relates to medical necessity of services performed and proper vetting of payers criteria
- Comply with federal and state laws, company policies and procedures
- All other duties as assigned
Essential Skills and Experience
- College degree or diploma from school of nursing – must be RN
- Clinical nursing experience working in hospital environment, preferably in ER, Critical Care or diagnostic services
- Minimum 5 years of related experience and/or training in utilization review or patient accounting
- Moderate computer proficiency, including working knowledge of Microsoft Word and Excel
- Excellent interpersonal and communication skills
- Mathematical skills: ability to calculate values using addition, subtraction, multiplication and division
- Ability to read and interpret an extensive variety of documents such as medical records, patient care systems, instructions, policies and procedures in written (in English) and diagram form
- Ability to write routine correspondence (in English)
- Ability to define problems, collect data, establish facts and draw valid conclusions
- Strong customer service orientation
- Strong team player
- Commitment to company values
