Billing and Revenue Recovery Officer-Billing and Recoveries

Job holder is responsible for the identification, mitigation, and prevention of denials along with preparing reports on clinical disputes based on the criteria documented. Assists with day-to-day revenue cycle denial operations and supports process improvement initiatives for coding, billing, and collections activities associated with Denial Prevention.ResponsibilitiesMonitors compliance with the rules and the contractual terms and agreement with the insurance companies and DOH Guidelines.Ensures compliance by the facility pricing structure and the rules for the different patient categories (including self-payer) with implementation.Prepares submission for all the patient invoice (Claims) through electronic means.Maintains and reports incorrect charges and charges not captured to Team Billing Lead or Billing Manager. Bills all secondary claims processed on a daily basis that are produced by the billing system.Ensures that DRG revisions are billed on a timely manner according to the billing policy.Maintains a high level of productivity while maintaining accuracy.Maintains a working knowledge of all universal billing guidelines for all assigned payers.Assists and works on all HCPCS revisions for rebills daily.Analyzes and rebills late charges. Rebilling must be done for all late charges according to current policies.Organizes, negotiates, and communicates clinical claim denials with internal clinical staff and the financial services department, as well as external claims representatives of a variety of insurers.Participates in external payer meetings, presenting payer performance related to denials.Serves as the Subject Matter Expert (SME) for clinical denials documentation and payer clinical guideline.Conducts follow-up on claims unpaid, partially paid or denied, including appeals and resubmission to the insurance company.Maintains claims documentation.Assists in the development of reporting mechanisms to identify trends.Delivers solutions to simpler issues facing the employees and presents complex issues to the Senior Billing and Revenue Recoveries.Corresponds with different vendors for the purpose of account verification and details of payment.Consults with other disciplines and other ancillary departments (i.e. physician, coding, OR, cardiology, pharmacy, purchasing, case management, respiratory therapy, clinical documentation specialists, etc.) as needed to obtain necessary documentation to support the clinical appeal and implement prevention.Promotes effective communication strategies within the team and maintains interdepartmental liaison where necessary.Manages to work with all stakeholders when identifying trends that can lead to inappropriate denial.Proactively identifies problems and opportunities for improvements related to system usage, training and end user education, practice and user trends and makes recommendations to the Manager of Revenue Recovery for resolution.Identifies, monitors and presents monthly denial performance accompanied with case studies and recommendations for process improvement.Manages to respond to verbal and written inquiries in a timely manner.AccountabilitiesMaintains and creates invoices and billing materials to be sent directly to a customer or patient. Ensures payment history, upcoming payment information or other financial data into an individual account.QualificationsRequired:Extensive knowledge of healthcare revenue cycle systems.Minimum of (5) years of healthcare customer service, claims, denials, appeals, compliance or related experience.Strong knowledge of third‑party payer reimbursement, eligibility verification process and government and payer compliance rules.Knowledge of general medical terminology, CPT, ICD‑9 and ICD‑10 coding.Strong knowledge of third‑party payer reimbursement, eligibility verification process and government and payer compliance rule.Desired:Experience in a large healthcare facility.Experience in training and staff development.Educational QualificationRequired:Bachelor in Accounting/Finance/Commerce or relevant field.Desired:Clinical Coding Certification, BS in Accounting, Finance, Business Administration or Healthcare.Master's in Business Administration or Healthcare preferred.Healthcare Certification (FHFMA and/or FACHE) preferred.#J-18808-Ljbffr