Investigates health plan denials to determine appropriate action and provide resolution.
Essential Job Functions:
1. investigates insurance denials to identify action necessary.
2. Corrects claims based on denials, complaints and audits and rebills using payor approved process.
3. Determines need for payor appeal and sends individualized appeal letter. Monitors appeals for resolution
4. .Adjusts denials determined to be appropriate using the corresponding adjustment code(s).
5. Works the accounts that meet denial management criteria and coordinates resolution with other departments. Denial management criteria include accounts that have potential financial impact such as authorization and refer denials, bundling issues and medical necessity for all assigned payers.
6. Logs all denials including actions and resolution on Denial spreadsheet.
7. Identify denial pattern to identify potential process improvement.
8. Produces quarterly denial reports.
License, Certification, Education or Experience:
REQUIRED for the position:
• High School graduate or equivalent.
• 1 year previous experience in professional billing.
• Knowledge and experience in working with health care insurers' and their reimbursement systems , especially Medicare, Medicaid, Workers Compensation, Motor Vehicle and contract payers.
• A good understanding of CPT, Modifiers, HCPC, ICD-10 codes and medical terminologies.
• Demonstrated problem solving ability.
• Ten-key by touch
DESIRED for the position:
• College degree/Vocational training in billing or business