Appeals Analyst Full Time chez Hughston Clinic

Menu

Careers Home

Current Openings

Appeals Analyst Full Time

Position Goal: 

Utilize coding certification knowledge and experience to monitor contractual allowances; analyzing and pursuing appeal opportunities with payers and networks, and reporting appeals performance.  Perform claim audits to ensure billing compliance with coding rules and guidelines as well as payer-specific policies.  Analyzes revenue cycle processes in order to develop tools and guidelines for educational opportunities.  Conducts research initiatives to support overall billing compliance.

Position Responsibilities:

• Implements processes for identifying under-allowed claims using Rivet Payer Performance and other available tools
• Leverages coding knowledge to focus specifically on surgical/procedure based claims and medical necessity denials to identify appeal opportunities
• Trends surgical claim billing errors by payer, provider, etc. and collaborates with the Revenue Cycle Educator to identify gaps in training and develop educational materials
• Analyzes zero pay reports with special attention to surgical/procedure claims to evaluate billing accuracy regarding the correct use of ICD-10, CPT, HCPCs coding
•  Reviews and analyzes EOBs for identified under-allowed and denied claims
• Verifies applicable contract by, as dictated by operational procedures: reviewing EOB messages, reviewing patient ID card, verifying member information for managed care plans
• Uses feedback and experience to refine communication skills and tools for use in preparing written, online, fax and telephone appeals
• Batches appeals, when applicable, by payer or network, by CPT/HCPCS code combination, by error type, or by provider
• Compiles and submits appeals and monitors for proper reimbursement
• Uses RIVET Payer Performance and Claim Resolution to track appeals and recoveries
• Establishes and cultivates helpful and effective contacts in payer or network offices
• Establishes follow-up protocol with payers and networks
• Monitors and tracks contractual, billing, registration, and posting errors, and provides continuous feedback to the Manager of Revenue Optimization Management
• Collaborates with the Revenue Cycle Educator and Chief Compliance and Revenue Integrity Officer to identify revenue cycle education and training opportunities and to develop periodic and recurring training materials (newsletters, bulletins, etc.)
• Assists, as needed, with special projects regarding provider payer compliance and other revenue cycle compliance initiatives as identified by the Chief Compliance and Revenue Integrity Officer
• Acts as an escalation point for the RIVET Team on possible appeal opportunities by analyzing medical coding compliance and billing information for accuracy, suspicious activity and compliance with healthcare regulation
• Actively reviews payer bulletins, memos, etc. to analyze potential impacts to billing procedures and reimbursement methodologies and builds a repository of updates for dissemination to key stakeholders
• Participates in meetings to discuss ongoing trends and issues regarding the administration of managed care contracts
• Cross-trains and performs appeals analysis within Hospital and Ambulatory Surgery Center claims, as needed
• Maintains the strict confidentiality required for medical records and other data
• Participates in professional development efforts to ensure currency in managed care reimbursement trends

Experience:

Required:

• Five years with insurance claims/related experience, CPT and ICD-10 terminology experience or
• Three years of above described experience with a Associates degree or higher in related field

Education:

Required:

• High school diploma or equivalent

Preferred:

• Associates degree or higher

Special Qualifications

 Required:

• Up-to-date coding certification; either CPC or coding credentials via AHIMA.
• Knowledge and PC skills, with proficiency in utilizing Microsoft office products (Word, Excel, Outlook, PowerPoint, etc.)
• Knowledge of medical terminology.
• Demonstrated skill in written and oral communication with colleagues, supervisors, and payer/network personnel.
• Demonstrated skill working in a team-oriented structure to achieve goals.
• Must be able to work independently

Preferred:

• Experience conducting revenue cycle / billing related audits
• Knowledge of networks, IPAs, MSOs, HMOs, PCP and contract affiliations.
• Knowledge of the health care professional services billing (physicians and related health care professionals) and reimbursement environment.
• Knowledge of major types of practice management system (PMS) and EOB imaging systems. 
• Knowledge of managed care contracts and compliance.Demonstrated skill in gathering and reporting claims information.

 The Hughston Clinic, The Hughston Foundation, The Hughston Surgical Center, Hughston Clinic Orthopaedics, Hughston Medical, Hughston Orthopaedics Trauma, Hughston Orthopaedics Southeast and Jack Hughston Memorial Hospital participate in E-Verify. This company is an equal opportunity employer that recruits and hires qualified candidates without regard to race, religion, color, sex, sexual orientation, gender identity, age, national origin, ancestry, citizenship, disability, or veteran status.