Strategic Revenue Optimization Specialist

Titan Healthcare Management Solutions

Job Description

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.

Minimum Qualifications

  • 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.
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