Medical Billing Claims Specialist

Job Overview:At Aspire Hospital, the Denials Specialist is responsible for coordinating and monitoring the denial management and appeals process in a collaborative environment with revenue cycle management and clinical partners at various Aspire facilities

This position will be responsible for working assigned specialties and combines clinical knowledge to reduce financial risk and exposure caused by front end claim edits and retrospective denial of payments for services provided

This position will collaborate with physicians, revenue cycle personnel, and payers to successfully clear front end claim edits, appeal clinical denials, and address customer service inquiries

Additionally, this position will collaborate with key stakeholders and assist in developing appeal strategies to include reference material for staff, letter templates, and regular feedback for revenue cycle coding staff; and functions as clinical subject matter expert related to coding denials and appeals

Communicates openly in a transparent and professional demeanor during all interactions with customers and co-workers while providing clear and concise communication of trending and findings to both front line team members and senior executives

Communicates to partners, revenue cycle staff, customers, and third party payers by telephone,

Functions as an educational liaison to clinical staff and revenue cycle staff as needed on payer denials, denial reason and trending, interpretation of payer manuals, medical policies, and local/national coverage determinations

Performs data mining and reporting activities that identify net positive impactful opportunities in denials and adjustments for the individual facilities and the system

Works assigned claim edit and follow up work queues and meets the assigned productivity standards on a daily basis as well as assigned patient account work queues and responds with resolutions within the expected time frame

Acts as a liaison for issues affecting various teams (coding, revenue integrity, accounts receivable (AR) follow up, etc.) of the revenue cycle while also providing support when IT related or systematic changes are needed

Analyzes data from various sources (medical records, claims data, payer medical policies, etc.), determines the causes for denials of payment and partners with management to implement strategies to prevent future denials

Integrates the payer medical policies, case specific medical documentation, and claims information into a concise appeal letter, including appropriate medical records submission

Performs timely review of medical records and remittances for denials in order to determine root cause and appropriateness

Partners with revenue cycle leadership and peers and clinical operations to reduce denials

This includes reviewing claim edits and denials and/or inquiries referred from other departments and assists in identifying root causes

Investigates the validity of the reasons for the denials and determines the need for or feasibility of submitting appeals

Works with revenue cycle management and staff to ensure claim edit/denial trending data is accurate and that all metrics are reported appropriately including specific current procedural terminology (CPT)/healthcare common procedure coding system (HCPCS), denial reasons, and appeals

Monitors recovery of payments and trends to identify corrective measures needed to prevent future edits/denials

Analyzes claim edits/denials to identify new trends, opportunities, and educational feedback as needed

This includes, but not limited to, feedback to coding, clinical service areas, physicians, and other revenue cycle staff

Makes recommendations to revenue cycle leadership on operations and root causes and assists in development of strategies to avoid future claim edits and denials

Provides education to revenue cycle team and attends monthly billing staff meetings as appropriate

This is not intended to be all inclusive; the employee will also perform other reasonably related business/job duties as assigned

Aspire Hospital reserves the right to revise job duties and responsibilities as the need arises

Qualifications

High School diploma or equivalent education (examples include: GED, verification of homeschool equivalency, partial or full completion of post-secondary education, etc.)

Five years of certified appeals denials or equivalent on the job experience

CERTIFICATIONS, LICENSES AND REGISTRATIONS not requited but recommended

Certified Professional Coder (CPC) through the American Academy of Professional Coders (AAPC), Certified Coding Specialist (CCS) through the American Health Information Management Association (AHIMA), or an approved Specialty Society Coding Certification Not required but prefered.

Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles MUST HAVE

Demonstrates the ability to think critically, work independently, and be self-motivated for the role MUST HAVE

Experience with computer database management and Microsoft Office software

Preferred but not required

Job Type: Full-time

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift

Work setting:

• Office

Work Location: In person