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Responsible for the duties and services that are supportive to the Clinical Appeals Team. Clarifies and verifies details of government denials (Medicare and Medicaid) and Managed Care/Commercial denials. Tracks denial information, appeal due dates, and provides necessary details to The Clinical Appeals Nurses. Performs assigned duties such as contacting payers to verify an account has been denied, verify the reason for denial, obtain all pertinent information needed to submit an appeal, and follow up for decisions on all appealed accounts. Responsible for maintaining denial work queues. In doing so, ensures that all denials are referred to Appeals Nurses timely. Documents, forwards, resolves incoming mail and correspondence
Contacts payers to determine reason for denials and obtain all pertinent information related to the denial
Obtains necessary information needed to complete the appeal
Follows up with payers on all appeal determinations
Manages denial work queues and all denial referral sources
Completes data entry in the Denial database for tracking, trends, and analysis
Provides Clinical Appeals Nurses with details of the denial
Contacts facilities for additional information when necessary
Maintain contact with Patient Financial Services on issues related to claims and billing
Assist in mailing out appeal letters and other office functions
Any other duties as assigned by the Director
HS Diploma or equivalency required
Post HS education preferred
Must have minimum of 2 years' experience with Medicare/Medicaid, Commercial/Managed Care insurance billing, collections, payment and reimbursement verification and/or refunds.
General hospital A/R accounts knowledge is preferred
College education, previous Insurance Company claims experience and/or health care billing trade school education may be considered in lieu of formal hospital experience.
Experience with the Medicare/Medicaid, Commercial/Managed Care billing process
Understanding of denial language
Experience with Medicare Remote -- DDE
Understanding of and exposure to Medicare Recovery Audit Contractor and Managed Care Audit process
Our Mission: WHY WE EXIST. To extend the healing ministry of Jesus Christ. Our Core Values: WHAT WE BELIEVE IN.DIGNITY Respect for the worth of every person, recognition and commitment to the value of diverse individuals and perspectives, and special concern for the poor and underserved. INTEGRITY Honesty, justice, and consistency in all relationships. EXCELLENCE High standards of service and per...formance. COMPASSION Service in a spirit of empathy, love, and concern. STEWARDSHIP Wise and just use of talents and resources in a collaborative manner.Our Vision: WHAT WE ARE STRIVING TO DO. CHRISTUS HEALTH, a Catholic health ministry, will be a leader, a partner and an advocate in the creation of innovative health and wellness solutions that improve the lives of individuals and communities so that all may experience God's healing presence and love. Our Name and Symbol:WHO WE ARE. CHRISTUS is Latin for "Christ," and proclaims publicly the core of our mission. OUR NAME choice also recognizes the heritage of our two congregational sponsors, the Sisters of Charity of the Incarnate Word in Houston and San Antonio. Jesus Christ is the Incarnate Word, the Word of God made flesh. It is, therefore, only fitting that it is in another form of His name that our health ministries are called together. OUR SYMBOL Reflects the healing ministry of Jesus Christ - a combination of a medical cross and a religious cross. The flowing banner on the cross is a common symbol of the risen Christ, while the royal purple signifies Christ. The flowing banner also conveys a sense of motion as we move forward into a new era of service to our communities.