- AS/AA degree in Accounting or Business Administration highly desired.
- Past work experience of at least 2 to 5 years revenue cycle either in billing, reimbursement or collections including but not limited to Medicare, Medicaid and Managed Care reimbursement methodologies is required.
- Independent and self directed.
- Organizes, prioritizes and coordinates multiple activities and tasks.
- Works with initiative, energy and effectiveness in a fast paced environment.
- In depth knowledge of insurance and governmental programs, regulations and billing processes (e.g. Medicare and Medicaid), for managed care contracts is required.
- Must be able to interpret contract language and various factors that make up payment methodologies including but not limited to: DRG, APC, ASC, Fee schedules, per diems, carve outs, stop-loss provisions, cost thresholds, outliers, bundling, percent of charges, Implantables and case rates.
- Must be able to perform accurate calculations and have analytical reasoning skills.
- Must be able to work independently and on teams as needed.
- Experience with Contract Management systems preferred.
- Basic computer skills are required. Knowledge of Excel worksheets is essential.
- Strong mathematical skills required.
- Strong written and verbal communication skills and organization abilities are required.
- Accuracy, attentiveness to detail and time management skills are paramount to success.
- Must be able to work in a collaborative environment.
- Evaluates variances on paid claims.
- Performs contract analysis to validate accuracy of programmed contract rules.
- Works independently to identify collectable underpaid amounts through appeal or reconsideration.
- Ensures reimbursement and follow up is accurate, timely and compliant.
- Initiates timely appeals and reconsiderations with payers by telephone, letter, email or other electronic media or spreadsheets.
- Perform follow up with regulatory agencies as may be required for challenged claims.
- Track and document underpayment reconsideration and appeals in contract management system.
- Accurately calculates and enters adjustments into the host system while appeals are pending. Ensures that batches are finalized at the close of business daily.
- Documents all activities in the contract management system.
- Assists with appeals for technical denials as needed.
- Addresses aged accounts in a timely manner to reduce Accounts Receivables and maximize reimbursements due under contract.
- Assists in efforts to maintain contract/ underpayment calculation integrity by monitoring system issues and serves as a liaison between Managed Care Recovery and PFS IT.
- Participates in team development projects and offers solutions to identified payer issues.
- Mentors new team members as directed.
- Assist other departments perform claim analysis as needed.
- Assimilates documentation to support reconciliation or appeal.
- Identified and reports data and collection trends/ barriers to claim resolution.
- Meets and/or exceeds production goals as defined.
- Other duties as assigned.