Denials Management Analyst

Description

Location: SGMC Patient Financial Services

Department: REVENUE CYCLE MEDICAL GROUP

Schedule: Full Time, 8 HR Day Shift, 8-5

Position Summary

The Denials Management Analyst is responsible for thorough understanding of existing and future managed care payment methodologies such as fee for service and fee schedule in order to effectively analyze zero paid, underpaid, overpaid, and denied insurance claims. The analyst is responsible for timely and accurately interpreting all payer contracts and regulations to determine the correct payer denial. Responsible for determining the optimal combination of rebilling, collections, and follow-up activities to ensure correct reimbursement to include extensive phone, fax, and written correspondence with payers. This includes coordination with all payers, Professional Coders, Billers, Patient Access Services, Finance, Accounting and other departments as necessary. This position is responsible for timely and accurately reviewing and trending all payer contractual adjustment variances. Responsible for preparing all necessary support information, education material for clinic staff and providers. Responsible for identifying trends in denials. Daily review of claims to determine appropriate appeal or claim reprocessing/reconsiderations to represent correct processing of insurance claims. Responsible for knowing all timely filing deadlines for each designated payer and prioritizing denials appropriately.

Knowledge, Skills & Abilities

• Technical/system skills/knowledge: PC and Windows literacy required; prefer knowledge of, or experience with, EPIC PB Resolute and Microsoft Office applications with strong knowledge of Microsoft Excel required.
• Extensive knowledge of insurance/managed care, to include: Medicare; Medicaid (Georgia); Medicaid CMO’s,Tricare (Standard, Extra and Prime); VA; Medicare Managed Care; Blue Cross (Georgia, Florida, out-of-state and FEP) and other commercial managed care plans.
• Working knowledge of CPT-4, HCPCS, and ICD-10.
• Reimbursement methodologies: percent of charges; fee-for-service; and fee schedule.
• Must have a thorough understanding and knowledge of: patient type; financial class; place of service codes; and relationship codes;
• Related regulatory and legal requirements: Medicare Secondary Payer Questions; medical necessity; Medical Reviews and Appeals.
• Interacts with: patients; other departments; physician offices; acute medical care providers; insurance companies; employers; Medicare administrative contractors; utilization review companies; state regulatory agencies, GMCF, Medicaid.
• Knowledge of medical terminology.
• Strong verbal/written communication skills.
• Highly organized with the ability to prioritize work.
• College degree or coursework preferred.
• CPAR preferred
• Types 40 wpm accurately.
• Clinical background beneficial.
• Professional coding background preferred.
  
  

WORKING CONDITIONS - ADA INFORMATION

Modern, well lighted, air conditioned, general work area. Moderate noise level. Occasional overtime required. Ability to sit, stand or walk for moderate periods. Safe and efficient operation of office equipment including: copier, fax, printers, computer, telephone, adding machine, Medifax, credit card machine, typewriter, paper shredder. Reading of printed materials, including physician orders. Listening and verbally responding to customers, staff, physicians and visitors. Moderately heavy lifting {0-25 lbs.}, reaching, stooping, pushing, pulling, bending, and twisting.