- Maintain the integrity of information in each appeal produced by the Firm
• Review a high volume of written appeals to ensure information is medically accurate
• Use, protect and disclose patients’ protected health information (PHI) only in accordance with the Health Insurance Portability and Accountability Act (HIPAA) standards.
• Research payer denials related to referral, pre-authorization, notifications, medical necessity, non-covered services, and billing resulting in denials and delays in payment.
• Make recommendations for workflow revisions to improve efficiency and reduce denials.
• Review payor communications, identifying risk for loss reimbursement related to medical policies and prior authorization requirements; escalates potential issues to clinical stakeholders, managed care contracting, and Revenue Cycle leadership as appropriate.
• Identify opportunities for process improvement and actively participate in process improvement initiatives.
• 4-year degree required
• Must be a Registered Nurse with clinical experience
• Experienced in medical chart review
• Hospital nursing experience
• Strong written communication skills
• Basic knowledge of MS Excel and the ability to learn proprietary databases
• Ability to meet on-going deadlines
• Exceptionally detail-oriented
• Must work cooperatively and efficiently under pressure
• Must be goal-oriented
• Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear.
• Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress.
• Work Environment: The noise level in the work environment is usually minimal.
Originally posted on Himalayas
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