Responsible for the audit of paid ‘zero balance’, short pay accounts, and other assigned hospital medical insurance claims. This includes identification and verification of underpayments, preparation of appeals/grievances to the insurance plan for accurate payment, and assistance with the collection and resolution of their appeals on assigned plan contracts.
Essential Job Duties/Responsibilities
- Comprehensive audit of hospital insurance claims payments, including Medicare and Medicaid coding rules, authorizations, generally accepted coding, and claims payment standards.
- Audit includes all necessary research to correctly verify claim payment accuracy or denial legitimacy, including telephonic communication with the plan where necessary.
- Analysis of contract language to prospectively identify potential sources of payment error.
- Identification and verification of underpayments made to the hospital by the insurance plan.
- Formulation of appeal/grievance reason and argument logic, including accurate calculation of short paid amount, drafting appeal or reconsideration letter and/or phone/fax/email/payor portal submission.
- Audit of paid appeal amounts to verify partial or complete payment. Draft and submit escalated or secondary appeal as required for underpaid accounts.
- Assist with the collection of appeals, including telephonic communication with the plan in cases where that would result in faster or more accurate payment of the appeal.
- Working knowledge of Commercial, Medicare, and Medicaid claims to include rules/reimbursement methodologies.
- Working knowledge of hospital/facility billing, coding rules and guidelines, and the UB04 claim form.
- An understanding of contract payment terms and pricing claims.
- Minimum 1-year Microsoft Office experience, to include Word and Excel required.
- Certified Professional Coding (CPC) certification or equivalent preferred.
- Certified Outpatient Coding (COC) certification or equivalent preferred.
- High school diploma or equivalent.
- Excellent oral and written communication skills.
- Customer and client services experience.
Remote Work Requirements
- Frequently required to stand; walk; sit; occasionally use hands to finger, handle or feel objects, tools or controls; reach with hands and arms; balance; stoop, kneel, crouch or crawl; talk or hear.
- Able to establish a secure, secluded working environment ensuring both HIPAA compliance and the ability to work during scheduled work hours without distractions/interruptions.
- Dependable high-speed internet.