Managed Care Revenue Optimization Claims Analyst - FT - Days - MSS - Hybrid Eligible - Memorial Healthcare System
Miramar, FL
About the Job
Location:
Miramar, Florida
At Memorial, we are dedicated to improving the health, well-being and, most of all, quality of life for the people entrusted to our care. An unwavering commitment to our service vision is what makes the difference. It is the foundation of The Memorial Experience.
Summary:
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:
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.
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.
Responsible to meet and maintain production and quality standards defined by department policies and procedures.
Responsible for identifying and reporting to Management payment and denial trends for assigned payors.
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.
Competencies:
ACCOUNTABILITY, ACCURACY, CUSTOMER SERVICE, MANAGED CARE COMPLIANCE APPEALS AND TRENDING, PROBLEM SOLVING, RESPONDING TO CHANGE, STANDARDS OF BEHAVIOR, TEAM WORK, WORKLOAD MANAGEMENT
Education and Certification Requirements:
High School Diploma or Equivalent (Required)
Additional Job Information:
Complexity of Work: Requires critical thinking and effective communication skills. Must be able to demonstrate ability to make independent decisions. Requires detailed knowledge of government and managed care insurance terminology and reimbursement methodologies. Must have knowledge of federal and state regulations and laws/statutes related to payment for medical services. Requires knowledge of proper billing and coding of hospital services. Must be able to formulate and write formal business communications. Intermediate knowledge of Microsoft Word and Excel. Required Work Experience: Two (2) years experience working in a hospital/physician business office, managed care collections or managed care claims environment required.
Working Conditions and Physical Requirements:
Miramar, Florida
At Memorial, we are dedicated to improving the health, well-being and, most of all, quality of life for the people entrusted to our care. An unwavering commitment to our service vision is what makes the difference. It is the foundation of The Memorial Experience.
Summary:
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:
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.
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.
Responsible to meet and maintain production and quality standards defined by department policies and procedures.
Responsible for identifying and reporting to Management payment and denial trends for assigned payors.
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.
Competencies:
ACCOUNTABILITY, ACCURACY, CUSTOMER SERVICE, MANAGED CARE COMPLIANCE APPEALS AND TRENDING, PROBLEM SOLVING, RESPONDING TO CHANGE, STANDARDS OF BEHAVIOR, TEAM WORK, WORKLOAD MANAGEMENT
Education and Certification Requirements:
High School Diploma or Equivalent (Required)
Additional Job Information:
Complexity of Work: Requires critical thinking and effective communication skills. Must be able to demonstrate ability to make independent decisions. Requires detailed knowledge of government and managed care insurance terminology and reimbursement methodologies. Must have knowledge of federal and state regulations and laws/statutes related to payment for medical services. Requires knowledge of proper billing and coding of hospital services. Must be able to formulate and write formal business communications. Intermediate knowledge of Microsoft Word and Excel. Required Work Experience: Two (2) years experience working in a hospital/physician business office, managed care collections or managed care claims environment required.
Working Conditions and Physical Requirements:
- Bending and Stooping = 40%
- Climbing = 0%
- Keyboard Entry = 80%
- Kneeling = 0%
- Lifting/Carrying Patients 35 Pounds or Greater = 0%
- Lifting or Carrying 0 - 25 lbs Non-Patient = 40%
- Lifting or Carrying 2501 lbs - 75 lbs Non-Patient = 0%
- Lifting or Carrying > 75 lbs Non-Patient = 0%
- Pushing or Pulling 0 - 25 lbs Non-Patient = 40%
- Pushing or Pulling 26 - 75 lbs Non-Patient = 0%
- Pushing or Pulling > 75 lbs Non-Patient = 0%
- Reaching = 0%
- Repetitive Movement Foot/Leg = 0%
- Repetitive Movement Hand/Arm = 60%
- Running = 0%
- Sitting = 60%
- Squatting = 0%
- Standing = 60%
- Walking = 60%
- Audible Speech = 80%
- Hearing Acuity = 80%
- Smelling Acuity = 0%
- Taste Discrimination = 0%
- Depth Perception = 60%
- Distinguish Color = 60%
- Seeing - Far = 60%
- Seeing - Near = 60%
- Bio hazardous Waste = 0%
- Biological Hazards - Respiratory = 0%
- Biological Hazards - Skin or Ingestion = 0%
- Blood and/or Bodily Fluids = 0%
- Communicable Diseases and/or Pathogens = 0%
- Asbestos = 0%
- Cytotoxic Chemicals = 0%
- Dust = 40%
- Gas/Vapors/Fumes = 0%
- Hazardous Chemicals = 0%
- Hazardous Medication = 0%
- Latex = 0%
- Computer Monitor = 80%
- Domestic Animals = 0%
- Extreme Heat/Cold = 0%
- Fire Risk = 0%
- Hazardous Noise = 0%
- Heating Devices = 0%
- Hypoxia = 0%
- Laser/High Intensity Lights = 0%
- Magnetic Fields = 0%
- Moving Mechanical Parts = 0%
- Needles/Sharp Objects = 0%
- Potential Electric Shock = 0%
- Potential for Physical Assaul
Source : Memorial Healthcare System
