Utilize independent judgment and exercise discretion to ensure timely review and auditing of underpaid claims.
Analyze, collect underpayments and resolve claims with discrepancies from expected payment to ensure payors are in payment compliance with their contracted terms.
Compile billing, and payor documentation to create training documents.
Initiate and follow through with all relevant parties to ensure corrective actions are implemented (i.e., pursue underpayments, adjust expected reimbursement, address billing issues, negotiate settlements, etc.) according to payor specific processes.
Respond to payment discrepancies by creating appeal letters and articulating contract provisions to representatives from third party payors. Work directly with payor to recover payments.
Quantify payor trends and maintain productivity and accuracy standards in highly challenging environment. Prepare 2nd level appeals, recoveries and potential settlements
Ability to extrapolate complex claims data and payer information to accurately report trends and payor behaviors.
Develops dashboards and reports on key performance indicators, metrics, data points, and formulas to support management objectives.
Extract, load and reconcile large data sets from multiple system platforms and sources.
Review data to determine operational impacts, trends and areas for improvement.
Follow up on claim submissions to determine batch acceptance, rejection, or denial in a timely manner.
Research, correct, resolve, resubmit and appeal denied claims/services. Corresponds with insurance companies to resolve the issue; submits appeals per payor requirements.
Maintains collections rate for assigned payors at or above 70% of allowed charges.
Communicate with RCM leadership about payor updates, changes, and requirements.
Sort and file paperwork from health plans, patient charts, and payment correspondence.
Update Division of Financial Risk (DOFR) quarterly with staff and report issues to Manager.
Support the team in their efforts to provide payors with information or documentation necessary for payment of claims and/or any other account follow up required to recover payment within a required timeframe.
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