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Professional Non-Clinical
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2020-R0285071 Requisition #
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JOB SUMMARY / PURPOSE

Under direct supervision, this position is responsible for corresponding with both commercial and government health insurance payers to address and resolve outstanding insurance balances related to coding denials in accordance with established standards, guidelines and requirements. The incumbent conducts follow-up process activities through review of medical records and contact with providers, phone calls, online processing, fax and written correspondence, leveraging work queues to organize work efficiently. Work also includes reviewing insurance remittance advices, researching denial reasons and resolving issues through well-written appeals.
Work requires proactive troubleshooting, significant attention to detail and the application of analytical/critical thinking skills to analyze denials and reimbursement methodologies to bring timely resolution to issues that have a potential impact on revenues.
In addition, the incumbent must be able to communicate effectively with payer representatives and maintain professional communication with team members in order to support denials resolution.

ESSENTIAL KEY JOB RESPONSIBILITIES

1. Applies a thorough understanding/interpretation of Explanation of Benefits (EOBs) and remittance advices, including when and how to ensure that correct and appropriate payment has been received.
2. Communicates effectively over the phone and through written correspondence to explain why a balance is outstanding, denied and/or underpaid using accurate and supported reasoning based on EOBs, reimbursement, and payer specific requirements.
3. Review patient medical record to compare documentation and coding; change coding based on documentation to include diagnosis codes, modifiers, place of service, etc. Communicate with provider to resolve claims that require a written appeal or second level appeal.
4. Resubmits claims with necessary information when requested through paper or electronic methods.
5. Anticipates potential areas of concern within the follow-up function; identify issues/trends and conducts staff training to address and rectify.
6. Recognizes when additional assistance is needed to resolve insurance balances and escalates appropriately and timely through defined communication and escalation channels.
7. Resolves work queues according to the prescribed priority and/or per the direction of management and in accordance with policies, procedures and other job aides.
8. Assists with unusual, complex or escalated issues as necessary.
9. Organizes open accounts by denial type or payer to quickly address in bulk with representatives over the phone, via spreadsheet, utilizing an on-line payer portal, etc.
10. Accurately documents patient accounts of all actions taken in billing system.
11. Other duties as assigned by management.

MINIMUM QUALIFICATIONS

Required Education
NA

Required Licensure and Certifications
NA

Required Minimum Knowledge, Skills and Abilities
Knowledge of health insurance, including coding.
Ability to communicate effectively and efficiently.
Proficient computer skills,with the ability to learn applicable internal systems.
Ability to work collaboratively with others toward the accomplishment of shared goals.

PREFERRED QUALIFICATIONS
 
High school diploma or equivalent preferred
Associates degree in related field
Completion of college level courses in medical terminology, anatomy and physiology, disease processes and pharmacology.
Completion of ICD-10 or CPT coding course.
1+ years coding experience
Insurance follow up experience
CPC Certification

About Us


CHI Memorial is a not-for-profit, faith-based healthcare organization dedicated to the healing ministry of the Church. Founded by the Sisters of Charity of Nazareth and strengthened as part of Catholic Health Initiatives, it offers a continuum of care including preventative, primary and acute hospital care, as well as cancer and cardiac care, orthopedic and rehabilitation services. CHI Memorial is a regional referral center of choice with 3,400 associates and more than 700 affiliated physicians providing health care throughout Southeast Tennessee and North Georgia.

Equal Opportunity Employment


Consistent with our Core Values, Catholic Health Initiatives employers are EEO/AA/M/F/Vets/Disabled Employers. Qualified applications will receive consideration for employment without regard to their race, color, religion, national origin, sex, sexual orientation, gender identification, protected veteran status, disability or any other legally protected characteristic

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