To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
Under the general direction of the Senior Manager, performs a wide range of duties involving the analysis of accounts denied by insurance carriers. Identifies issues resulting in the denial of claims. Takes corrective action to facilitate the re-billing and/or appeal of claims and the subsequent reimbursement. Accurately analyzes and resolves any issues created throughout the verification, billing and follow up process. Serves as the primary feedback mechanism to determine if pre-registration and registration policies and procedures are being adhered to. Reduce the provider liable accounts by working accounts as well as identifying the denial reasons.Works closely with managed care organizations, third party payors and registration staff, to ensure compliance to individual contract requirements in order to expedite reimbursement of accounts and protect the hospital from unnecessary financial loss.
- 1. Performs detailed analysis of provider liable accounts to identify the types of issues that result in the denial of claims. Uses good planning and problem-solving methods and resourcefulness to resolve issues (including any system problems). Follows up accounts by contacting both internal and external sources to clarify pre-certification, approval, timely filing, diagnosis or other information needed to address the denial reasons and resolve the account.
- 2. Analyzes system notes and other documentation as they pertain to the provider liable accounts. Tracks down requests for authorizations or prior authorizations from insurance companies. Takes corrective action to ensure timely re-billing of accounts or initiation of appeal, accurately documenting all actions in the system.
- 3. Writes effective appeal letters and coordinates with other parties to ensure that appropriate actions are taken to recover the maximum reimbursement from appeals.
- 4. Maintains complete understanding of the Access department and the SBO processes to effectively carry out assigned duties. Demonstrates a thorough understanding of provider liable reports worked and familiarity with all systems.
- 5. Using excellent analytical and decision-making skills manage the provider liable accounts in the file. Analyzes both governmental and non-governmental denials to determine the most appropriate method to comply. Identifies which accounts are possible write-offs, re-bills or appeals and takes corrective action or refers to the appropriate parties.
- 6. Works closely with utilization review department and combines efforts to deal effectively with accounts involving both technical and clinical denials in the provider liable file.
- 7. Uses established re-billing, collection and follow up procedures to effectively expedite prompt resolution of denied claims. Uses proper escalation procedures both internally and externally after exhausting all avenues for timely resolution of the denied claim.
- 8. Documents all activity regarding provider liable accounts in a clear and concise manner to aid in the resolution of issues for current operations or future review. Organizes and presents findings to payers and internal SBO management as required.
- 9. Has a complete understanding of the Provider Liable procedures in order to effectively carry out assigned duties. Demonstrates a thorough knowledge and understanding of each phase of the provider liable process and a familiarity with all systems involved.
- 10. Recognizes the key issues resulting in provider liable accounts and makes recommendation to improve the entire process in order to effectively reduce the number of these accounts. Look for ways to continually to improve the process that will result in a lower incidence of provider liable accounts.
- 11. Produces daily, weekly and monthly provider liable statistics utilizing report writer and/or spreadsheet software.
- 12. Performs all other duties or special projects requested by supervisor and informs the supervisor of any pertinent information or problems that arise to maintain a smooth operation of the department.
Bachelors of Science degree in a business related field preferred, or equivalent work experience.
Position requires two (2) years or three (3) years experience in patient admitting activity and/or billing and follow up experience with knowledge of insurance authorization and billing requirements in a hospital/ healthcare computerized environment. Medical terminology and/or coding experience preferred.
Excellent analytical and organizational skills. Extensive knowledge of third party terminology and hospital coverage as it relates to pre-authorizations, billing and reimbursement. Demonstrated ability to interpret third party contracts. Excellent writing and computer skills. Ability to perform detailed analysis quickly and accurately.