Position is primarily responsible for reviewing, researching, and responding to written and emailed correspondence from providers, both professional and institutional, regarding claim denials based on clinical coding policies. Acts as a subject matter expert and handles more complex provider issues.
Location: Idlewild Ave, Tampa, FL
Department: Ops-Claims I
Reporting to: Supv, Claims Coding Rules
- Reviews and responds to written provider disputes, clearly and articulately outlining the payment discrepancy to the provider.
- Thoroughly researches post payment claims and takes appropriate action to resolve identified issues within turnaround time requirements and quality standards.
- Navigate CMS and State specific websites, as well as AMA guidelines, and compare to current payment policy configuration in order to resolve the providers payment discrepancy.
- Review medical records to ensure coding is consistent with the services billed and compares against the clinical coding guidelines in order to decide if a claim adjustment is necessary.
- Processes claim adjustment requests in Xcelys following all established adjustment and claim processing guidelines.
- Utilize SharePoint and Excel as necessary to work through daily inventory assignments.
- Identifies and escalates root cause issues to supervisor for escalated review.
- Reviews and responds to internal escalated provider disputes transferred by management and other associates.
- Acts as liaison with other departments when additional clarification is needed about claims payment policy disputes.
- Assists team members with training opportunities and coaching.
- Assists with special projects as assigned or directed.
- Required A High School or GED
- Required 3 years of experience in claim coding, claim processing or billing in a healthcare environment
- Preferred 1 year of experience in claims coding
Licenses and Certifications:
- Intermediate Demonstrated written communication skills
- Intermediate Demonstrated interpersonal/verbal communication skills
- Advanced Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
- Intermediate Other Ability to quickly research and absorb new payment systems
- Intermediate Other Knowledge of Medicare and Medicaid payment systems
- Preferred CPC, CSS or relevant certifications
- Required Intermediate Other Strong knowledge of electronic medical records/billing systems and medical terminology and abbreviations
- Required Intermediate Other Billing expertise in UB92, UB04, HCFA 1500 and/or other healthcare services