Major Responsibilities:

Researches and analyzes denied claims to ensure compliance with payor and/or government rules/regulations and determines appropriateness for appeal. Secures needed medical documentation required or requested by insurance carriers to support appeal process. Reviews and analyzes accounts; determines and writes appeal letters for technical appeals based on medical necessity. Collaborates with staff as needed on issues related to denials. Prepares claims for clinical appeal processing in the case of authorization and medical necessity denials. Prepares documents utilizing provider billing manuals to obtain billing guidelines and requirements and shares information as needed. Prioritizes appeals according to filing limitations established by the individual payor contracts. Responsible for ongoing documentation of denial status in denial software. Identifies and analyzes payor trends/issues and communicates with leadership on findings. Meets monthly with Denial Prevention Advisor to go over trends in denial categories and providing feedback for opportunities to increase revenue. Maintains a caseload and monitors day to day compliance of appeal decision time frames. Licensure, Registration, and/or

Certification Required:

None Required.

Education Required:

Bachelor's Degree in Finance, or related field, or equivalent knowledge.

Experience Required:

Typically requires 3 years of experience in Hospital billing, finance, medical necessity denials management, coding or related field.

Knowledge, Skills & Abilities Required:

Experience with current CPT and HCPCS coding nomenclature and rules, ICD-9/ICD10 coding conventions and clinical documentation standards. Previous clinical documentation and chart review experience along with understanding of medical terminology. Knowledge of appeals criteria and understanding of federal, state and local regulations. Excellent critical thinking and analytical skills, with a high attention to detail. Ability to meet deadlines while working in a fast paced environment. Ability to take initiative and work collaboratively with others. Strong computer skills, including high proficiency with Microsoft Office Suite. Desire to Enhance Knowledge, skills and abilities. Excellent writing skills necessary to facilitate the advanced appeal process.

Physical Requirements and Working Conditions:

Operates all equipment necessary to perform the job. Exposed to a normal office environment. This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.