Managed Care Revenue Optimization Analyst - FT - Days - MSS - Hybrid Eligible

Reviews and analyzes denials and short payments received from insurance plans to determine best plan for resolution. Takes action required to obtain payment in accordance with the terms of payor contract, applicable billing guidelines and/or Federal and State laws.

Responsibilities

Responsible to meet and maintain production and quality standards defined by department policies and procedures; Reviews and analyzes managed care balances related to short payments, denials or those aged with no response; Evaluates the authorization, coding, billing and correspondence to identify underlying issue and determine best course of action to be taken to collect; Compiles detailed written appeal document outlining position for payment; Tracks outcomes of requests for payment to ensure timely identification of additional actions needed; Reconciles and updates business system and reports with findings and formalizes appeal documents required for follow up action; Interacts directly with Department Clinical Team as needed to obtain pertinent clinical facts needed to support medical necessity of services provided; Creates and maintains spreadsheets of open accounts; Works directly with plan contacts to exchange data, identify root causes of issues and reconcile data to confirm resolution; Responsible for identifying and reporting to Management payment and denial trends for assigned payors

Requirements

High School Diploma or Equivalent; Two (2) years experience working in a hospital/physician business office, managed care collections or managed care claims environment; Critical thinking and effective communication skills; Ability to make independent decisions; Detailed knowledge of government and managed care insurance terminology and reimbursement methodologies; Knowledge of federal and state regulations and laws/statutes related to payment for medical services; Knowledge of proper billing and coding of hospital services; Ability to formulate and write formal business communications; Intermediate knowledge of Microsoft Word and Excel; Accountability; Accuracy; Customer Service; Managed Care Compliance Appeals and Trending; Problem Solving; Responding to Change; Standards of Behavior; Team Work; Workload Management