Billing And Collections Specialist Ii, Denials Management at DHR Health

Summary

FLSA STATUS: ☐ Exempt ☒ Non-Exempt MISSION STATEMENT: Our Mission is to improve the well-being of those we serve with a commitment to excellence: every patient, every encounter, every time. VISION: Our Vision is to create a world-class health system to advance medicine and increase access for the communities we serve by empowering caregivers to heal through compassion, knowledge, innovation, integrated care and excellence.

Position Summary

The Billing and Collections Specialist II is responsible for conducting quality assurance reviews on denied claims. When an appeal is necessary, the specialist drafts the appeal to payers using relevant clinical indicators, official coding guidelines, and documentation from the patient’s medical record. Basic knowledge of medical terminology, CPT/HCPCS codes and ICD10 codes are required.

Additionally, the specialist plays a crucial role in reporting quality results, tracking and identifying educational opportunities within the Revenue Cycle departments, addressing client subject matter needs, and contributing to educational support and training efforts.

Position Education/ Qualifications

• High School Diploma/GED required 2-3 years of experience in denial management, utilization review or prior authorization in a hospital, provider, or healthcare system.
• Experience in healthcare billing and reimbursement Experience with EMR system workflows Strong knowledge of health care services reimbursement methodologies Knowledge of claim forms and remittance advice, including coding and billing practices Ability to interpret contract language Working knowledge of medical terminology Knowledge of Microsoft Office Suite Excellent Customer Service Bilingual- English/Spanish, preferred Previous healthcare and hospital/professional experience preferred.
• Ability to use the internet to obtain information from Third Party Payers or other sources is preferred.
• Requires working with minimal to moderate interruptions

Job Knowledge/Experience

• Previous healthcare and hospital/professional experience preferred.
• Communicates clearly and concisely and is able to work effectively with other employees, patients and external parties Establishes and maintains long-term customer relationships, building rapport with other department staff Demonstrates proficiency in Microsoft Office applications and good working knowledge of Excel is preferred.
• Able to perform basic mathematical calculations, balance and reconcile figures, punctuate properly and spell correctly.
• Medical Terminology, ICD – 10, Codes, CPT Codes, HCPCS code, Modifier knowledge preferred.
• Ability to use the internet to obtain information from Third Party Payers or other sources is preferred.
• Requires working with minimal to moderate interruptions Occasional evening or weekend work may be required.

Position Responsibilities

• Promotes the facility mission, vision and values by effectively communicating them to others.
• Considers mission, vision and values in developing services, standards and practices Demonstrate expertise in handling denials and appeals.
• Draft detailed appeal letters with all necessary information.
• Manage and follow up on assigned insurance accounts Follow governmental billing and collection rules as outlined in payer manuals when interacting with insurance carriers.
• Utilize different software systems to verify eligibility and claim status Demonstrate proficiency in billing and following up on claims using online or billing software.
• Access payer websites as needed to retrieve information.
• Understand managed care contract terms to determine correct reimbursement levels.
• Serve as a subject matter expert on payer policies, reimbursement methodologies, and regulatory requirements Works with Revenue Cycle Management support team to ensure projects and meetings are productive and complete.
• Work with Management team and Providers to make sure their concerns are answered.
• Review denials weekly for trends and notify appropriate dept/staff of issues.
• Verifies data in medical chart for completeness and accuracy in regard to appropriate coding regulations and ethics.
• Reviews insurance explanation of

Benefits

• for procedures to ensure appropriate reimbursement.
• Monitors reimbursement of selected procedures on a continual basis.
• Review and maintain on a continual basis all bulletins and correspondence from carriers for up-to-date information.
• Review with Management team and providers that all rejections or denials for demographic, coding and insurance information are obtained, updated, and entered accurately into the host system, and eligibility has been done on presented insurance information.
• Knowledge of participating insurance plans accepted by the office.
• Actively participate in process improvement efforts.
• Serve as a liaison between the external Revenue Cycle Management team and onsite teams Compare payer reimbursement to expected payments and address discrepancies with insurance carriers.
• Contact patients to gather additional information for insurance purposes, if needed.
• Address faxes or messages from carriers within 24 hours to ensure timely and compliant resolution of denials.
• Follow up on assigned Accounts Receivable trackers or custom reports, contacting insurance carriers for payment or recoupments.
• Enter appropriate notes in host system Respond to insurance carrier correspondence in a timely manner.
• Identify accounts needing insurance billing/ rebilling or appeal Enter and maintain appealed accounts using appropriate indicators in host system Notify management of any compliance concerns or incidents.
• Ensure patient confidentiality is maintained in accordance with HIPAA policies and procedures.
• Attend educational conference calls and complete HealthStream learning modules on time.
• Productivity and Quality: Maintain required productivity and quality standards and adhere to QA process requirements.
• Work towards cross-training and familiarizing oneself with both professional and facility denials.
• Review and analyze denials reasons to identify trends and areas for improvement.
• Collaborate with internal teams to resolve denial issues efficiently Works with Revenue Cycle Management support team to ensure projects and meetings are productive and complete.

Benefits

• for procedures to ensure appropriate reimbursement.
• Monitors reimbursement of selected procedures on a continual basis.
• Review and maintain on a continual basis all bulletins and correspondence from carriers for up-to-date information.
• Exhibit a high-level production by assuring all assigned tasks are corrected and rebilled in a timely.
• Review with Management team and providers that all rejections or denials for demographic, coding and insurance information are obtained, updated, and entered accurately into the host system, and eligibility has been done on presented insurance information.
• Knowledge of participating insurance plans accepted by the office.
• Actively participate in process improvement efforts.
• Serve as a liaison between the external Revenue Cycle Management team and onsite teams May be required to assist other team members based on office demands Other duties as assigned LINES OF REPSONSIBILITIES: (Chain-of-command) Billing and Collections Supervisor → Billing and Collections Manager → Director of Revenue Cycle → Chief Revenue Officer

Customer Service

Provide excellent customer service to all DHR customers. All employees are required to attend the DHR C.A.R.E.S program which outlines the Customer Service Principals including: Commitment, Accountability, Respect, Excellence and Service.

Age Specific

Employees must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served in his/her assigned unit. The individual must demonstrate knowledge of principles of growth and development over the life span and possess the ability to assess data reflective of the patient’s status and interpret the appropriate information needed to identify each patient’s requirement relative to his or her age.

Americans With Disabilities Act

(ADA): A.