Description
Manages complex medical claims, acting as a subject matter expert to investigate, adjudicate negotiate#settlements, ensure compliance and mentor junior staff, focusing on accurate and timely and cost-effective claims resolution while maintaining strong communication with providers, payers and internalteams. Serve as subject matter expert, providing guidance on policy, regulations and complex#claims scenarios. ï‚· Conduct in-depth analysis, research discrepancies, prevent fraud and develop plans for#claims resolution. ï‚· Handles escalated inquires, build relationships with providers/payers and communicate#claims status. ï‚· Assist in training, coaching and provide senior support to less experienced team#members. ï‚· Review and process complex hospital claims and determine coverage based on policy,#medical necessity and contracts. ï‚· Able to work all aspects of Commercial Managed Care, Medicare Advantage, and#Medicaid Advantage Care accounts sliding between Financial Classes as needed for#Billing, Follow-up, Denials Management, Credit Balance and Account resolution. ï‚· Works closely with Manager and team to ensure timely claim submission within#established guidelines. ï‚· Represents department in on-going JOC meetings, creating, maintaining and sharing#excel spreadsheets detailing billing and reimbursement concerns, challenging carriers#and provider reps as needed to insure positive outcomes for HMC. Required Skills ï‚· Must show honesty, integrity, strong ethics, data entry skills and time management skills. ï‚· Strong understanding of Medetech and finThrive billing programs ï‚· Strong Verbal and written skills for preparing and presenting appeals, negotiating settlements and presenting reports to Senior Management. ï‚· Proactive approach to resolving discrepancies between insurance policy terms and provider charges ï‚· Ability to analyze complex data, identify issues and solve problems ï‚· Proven background in handling complex institutional or healthcare related claims ï‚· Proficiency with claims software and MS Office (especially Excel). ï‚· Strong time management, organization skills and ability to work independently or in a team ï‚· Good plus knowledge of ICS/HCPCS/CPT Coding and medical terminology ï‚· Knowledge of commercial, state and federal healthcare regulations Education: High School Diploma or GED is required, an Associate or Bachelor#s degree in Health#Administration or related Study preferred Experience: Eight plus (8+) years in the health insurance, hospital business office or claims#processing/management.
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