POSITION SUMMARY:
The Denial Management (DM) Representative studies to the Denial Management Supervisor. The DM Representative performs a key position in maximizing income for M3 and its Shoppers by using the DM Course of to facilitate well timed funds on full and partially denied claims. Using business normal greatest practices, the DM Representative collaborates with the Coding division and Shopper Medical Employees, to coordinate the evaluation, analysis and determination of assigned denials. The DM Representative persistently maintains pre-outlined productiveness and efficiency measures, to maximise correct reimbursement and speed up money collections. With a radical understanding of Income Cycle Management (RCM), the DM Representative determines and executes the most effective strategy for denial decision and rebilling, and assists with root trigger evaluation of denials.
MAIN POSITION REQUIREMENTS:
- Critiques denials in Info Methods (IS) and reprocesses claims, in accordance with Payer Contract Necessities.
- Evaluations Rationalization of Advantages (EOBs) for denial causes, and collaborates with Shoppers and Payers to facilitate denial decision.
- Critiques coding and documentation of billed providers, inside the relevant scope of apply, to confirm help of medical necessity and element of process carried out.
- Differentiates between medical and technical denials via EOBs, letters and affected person knowledge.
- Refers medical denials to the RCS Coding Specialist or different medical employees, as applicable to the scope of apply.
- Responds to denials and information appeals, as outlined by RCS Denial Management and Appeals Procedures, and in accordance with State and Federal Regulatory Necessities.
- Contacts the suitable third get together to determine attraction consequence and determines the relevant plan of action.
- Communicates with Shopper, by way of phone or IS, as applicable, to make clear coding discrepancies and guarantee modifications are documented by Shopper.
- Re-file claims not acquired by Service and performs comply with-up on all reprocessed claims.
- Facilitates RCS Refund Course of, when credit score balances are recognized.
- Communicates with sufferers and Shoppers, as applicable, to offer info relating to declare standing and the EMS DM Course of.
- Maintains ongoing communication with RCMS Employees and the RCS answerable for different features of the Income Cycle.
- Paperwork all account exercise within the relevant ORIGIN IS, in accordance with RCS Documentation Requirements.
- Identifies applicable escalation factors and works with the EMS DM Supervisor to resolve points.
- Assists with the identification of tendencies and root trigger evaluation, relative to denied claims, and communicates with the DM Supervisor and Director of EMS Operations, as applicable, to scale back reimbursement delays and reduce denials.
- Participates in High quality Assurance (QA) initiatives and completes audits, as requested by the RCS QA Analyst and RCS Management.
- Mentors new staff and assists with coaching, as requested by the AR Supervisor.
- Maintains a complete understanding of State and Federal Regulatory Necessities, relative to RCM, in addition to assets and instruments obtainable to collect info for denial assessment and attraction.
- Persistently meets pre-outlined productiveness metrics and efficiency requirements.
- Performs all obligations, in accordance with RCS Insurance policies and Procedures, and inside the applicable scope of apply, as designated by the extent of professional credentialing and State Particular Scope of Apply Tips.
- Maintains present skilled certification, as applicable, and in accordance with Meridian Human Useful resource Credentialing Insurance policies and Procedures.
- Ensures compliance with RCS HIPAA Privateness and Safety Insurance policies and Procedures.
- Attends required in-providers and coaching periods.
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MANAGEMENT RESPONSIBILITIES:
None
ADDITIONAL RESPONSIBILITIES & SKILLS:
- Demonstrates efficient, skilled verbal and non-verbal communication expertise.
- Demonstrates consideration to element and the power to use payer contract language to billing.
- Demonstrates the power to be versatile and work collaboratively with a number of inner and exterior groups, to determine and assist resolve enterprise-broad challenges.
- Demonstrates the power to successfully examine, analyze and drawback remedy.
- Demonstrates proficiency working with Home windows OS and Microsoft Workplace, together with Excel and Phrase.
- Efficiently completes all required competency exams with 80% proficiency.
KNOWLEDGE AND EXPERIENCE:
- Excessive Faculty diploma or GED required; school diploma most popular.
- Minimal 5 (5) years earlier expertise in Healthcare Billing or Affected person Monetary Providers.
- Complete information and demonstrated competency within the following areas:
- CPT /ICD-9 Codes and Medical Billing Terminology – CPC Most popular;
- Workflow Management, Apply Management and/or Medical Billing Info Methods;
- Payer Documentation Requirements;
- Medicare and Medicaid & Business Reimbursement Necessities;
- Minimal 5 (5) years current expertise with Business Third Celebration Insurance coverage necessities;
Job Sort: Full-time
Native candidates solely:
Required expertise:
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