Responsible for collections and/or refunds of highly complex cases. Performs functions necessary to facilitate payment recovery including research, appeals, and follow-up. Identify trends, potential resolutions, and escalate to a manager. Provide data related to reimbursement reductions, overages, delays, and non-payment. Evaluate the accuracy of contract modeling, communicate findings, and escalate as appropriate. Participate in payer meetings to resolve issues. Responsible for ensuring solutions implemented and goals achieved. Identify and monitor organization & payor rule changes and work to ensure compliance.
Ensure all assigned claims are followed up and/or appealed in a timely manner as per standard operating procedure (SOP); ensure maximum recovery of reimbursement.
Follow up on all appeals to ensure receipt and processing by carrier and prevent loss to untimely appeal
Evaluate contract management expected reimbursement and follow appropriate guidelines to report and escalate.
Evaluate overpayments and process timely as per procedures
Manage large volumes of line item denials, underpayments, and overpayments, and various appeal deadlines to prioritize workload and maximize reimbursement.
Ensure written appeals are clear, concise and within timely appeal limits.
Ensure appropriate supporting documentation is included with appeals.
Analyze retracted payments to determine appropriate course of action to recover reimbursement.
Prioritize work to facilitate payment of higher account balances.
- contract reimbursement
- Access spreadsheet
- Excel spreadsheet
- APR DRGs
- care payer requirements
- coding, NCCI edits
- Data Analysis
- Issue Resolution
- Years of experience: 5 years
- Experience level:Experienced
Working hours: 8 AM - 4 PM
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