Job description

Position Summary

Primarily responsible for thorough review of medical records and other medical documentation to determine appropriate billable services for hospital, and to construct appeals for payment based on medical necessity or payer specific guidelines or criteria. Responsible for providing clients trending, revenue cycle fail point analysis, case studies, and best practice remediation recommendations.

Duties and Responsibilities

• Build strong, lasting relationships with clients, payors and Revecore personnel
• Analyze medical records or other medical documentation to validate services, tests, supplies and drugs performed for accuracy related to billing for services rendered
• Ability to identify and interpret medical, radiological, laboratory or other tests and procedures as well as pharmaceutical drugs
• Ability to review and understand managed care contracts, hospital billing statements/bills and insurance denials
• Research commercial and governmental payor policies, clinical abstracts and studies, and other documentation related to claims payment to evaluate and appeal denied claims.
• Highly proficient with Interqual and MCG guidelines and demonstrate appropriate application to claim appeal argument.
• Understanding of patient accounting documents – UB04, EOB
• Perform research regarding denials and effectively communicate information to associates, colleagues, managers and clients
• Contact insurance company to obtain missing information, explain and resolve underpayments and/or denials and arrange for payment or adjustment processing on behalf of client
• Prepare and submit correspondence such as letters, emails, online inquiries, appeals, adjustments, reports and payment posting
• Perform denial trending for clients, identify fail points within the revenue cycle and on the payer side, present case studies to the client, and provide best practice recommendations to clients and Revecore managers.
• Maintain regular contact with necessary parties regarding claims status including payors, clients, managers, and other Revecore personnel
• Maintain confidentiality of information in compliance with company policy and HIPAA
• Attend client, department and company meetings
• Lead client meetings and perform consulting services to client’s as it relates to medical necessity of services performed and proper vetting of payers criteria
• Comply with federal and state laws, company policies and procedures
• All other duties as assigned

Skills and Experience

• College degree or diploma from school of nursing – must be RN
• Clinical nursing experience working in hospital environment, preferably in ER, Critical Care or diagnostic services
• Minimum 5-years related experience and/or training in utilization review or patient accounting
• Moderate computer proficiency, including working knowledge of Microsoft Word and Excel
• Excellent interpersonal and communication skills
• Mathematical skills: ability to calculate values using addition, subtraction, multiplication and division
• Ability to read and interpret an extensive variety of documents such as medical records, patient care systems, instructions, policies and procedures in written (in English) and diagram form
• Ability to write routine correspondence (in English)
• Ability to define problems, collect data, establish facts and draw valid conclusions
• Strong customer service orientation
• Strong team player
• Commitment to company values
• Microsoft Outlook
• Related Professional License/Certifications

Physical Demands and Work Environment

The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Physical Demands: While performing the duties of this job, the employee is occasionally required to walk; sit; use hands to handle or feel objects, tools or controls; reach with hands and arms; balance; stoop; talk or hear. The employee must occasionally lift and/or move up to 15 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.
• Work Environment: While performing the duties of this job, the employee is exposed to weather conditions prevalent at the time. The noise level in the work environment is usually moderate.

Job Type: Full-time

Pay: From $75,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Flexible schedule
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Vision insurance

Physical setting:

• Hospital
• Inpatient
• Outpatient

Schedule:

• 8 hour shift
• Monday to Friday

Supplemental pay types:

• Bonus pay

Work Location: Remote

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