Job description

Uses an appropriate problem-solving approach to plan services to support billing and collection efforts of all FHPG Family Care Centers, Specialty Clinics, and other FH employed or contracted providers billing in under the FH umbrella.

Responsible for denial and appeals claim processing for medical providers, and laboratories services ordered by FHPB, ensuring compliance and contractual obligations and State and Federal laws and regulations and generating appeals for denied or underpaid claims. Responsible for reviewing lab billing work queue & communicating medical necessity issues to providers prior to charges being forwarded to HB for billing. Assist in educating providers on Medicare LCDs and payer requirements for specific lab orders. Analyze all coding adjustments made on EOB to ascertain accuracy and validity. Determine and execute best approach for denial resolution and processing appeals in accordance with Federal, State and payer guidelines. Ensure timeliness of appeals, generate appeals based on dispute reason(s), request and obtain medical records as needed for appeal, document all actions taken during the appeal process and any required follow up. Assist manager in identifying coding errors that generate denials and help to establish front end charge review edits to decrease denials. Review claims with 22, 52 & 53 modifiers in the claims requiring attachments work queue, initiate request of records utilizing EPIC software, submit required documentation for claim following payer requirements. Work with Revenue Integrity Manager to utilize workflows set in place to minimize late charges, optimize revenue capture and identify trends within clinic areas that need attention.

Serves as the support for Clinics in understanding Medicare, Medicaid and individual payer requirements for billing. On new project acquisitions, education on payer requirements for billing. Communicates operational changes that result from system implementation to all pertinent users. Resolves issues at the point of service and provides feedback to end users and Management.Stays current with technological developments in systems administration technology and recommends ways to take advantage of new technology. Develops tools, procedures and training sessions for staff, AR Director, Clinic Managers, Regional Directors and Compliance Team. Maintains rapport with staff, AR Director, Clinic Managers, Regional Directors and Compliance Team by continuous contact to research and develop new services and methods, setting priorities and resolving problem situations. Provides feedback used to train and support all FHPG Providers and Staff as needed and directed by management.

Use detailed system knowledge to gather trending data regarding insurance denials. Provides report of denial root cause analysis with feedback to management. Assist all users in maximizing efficiencies of the system to meet growing hospital and practice demands. Demonstrates advanced knowledge of systems report writer and functionality. Assist in minimizing late charges, timely charge capture, timely appeal and or claim correction. Assist Revenue Integrity Management with implementation of the multiple interfaces and processes where applicable. Assist with implementation and ongoing process monitoring revenue capture at clinic sites where this is applicable. Maintain and generate reporting mechanism to track revenue and billing out of an ambulatory department. Track, work and report returning reimbursements and net revenue for ambulatory areas. Supports compliance as it relates to billing, coding and claim submission. Support and enhance the development of all practice groups new and currently present within the systems in use by clinics.

Prefer Bachelor Degree in Business, Healthcare Administration or Information Systems; experience may be accepted in lieu of education or formal training. Three years experience in physician group practice that utilizes EMR and Billing systems to performed daily activities. Greater than three years' experience in Clinic Practices and Clinic Billing. Certification in Coding either CPC or CCS-P.

Location: FirstHealth of the Carolinas · Practice Management
Schedule: Full Time - 40 Hours per Week, Day Shift, 8:30a - 5:00p

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