Managed Care Revenue Optimization Analyst - FT - Days - MSS - Hybrid Eligible

Memorial Healthcare System - Miramar, FL

Full-time

Miramar, FL

Hospitals

About the position

Location: Miramar, Florida. At Memorial, we are dedicated to improving the health, well-being and, most of all, quality of life for the people entrusted to our care. An unwavering commitment to our service vision is what makes the difference. It is the foundation of The Memorial Experience. As a Managed Care Revenue Optimization Analyst, you will play a crucial role in reviewing and analyzing denials and short payments received from insurance plans to determine the best plan for resolution. Your responsibilities will include taking the necessary actions to obtain payment in accordance with the terms of payor contracts, applicable billing guidelines, and Federal and State laws. You will be responsible for meeting and maintaining production and quality standards defined by department policies and procedures. In this position, you will review and analyze managed care balances related to short payments, denials, or those aged with no response. You will evaluate the authorization, coding, billing, and correspondence to identify underlying issues and determine the best course of action to collect. Additionally, you will compile detailed written appeal documents outlining the position for payment and identify and report payment and denial trends for assigned payors. Interacting directly with the Department Clinical Team as needed to obtain pertinent clinical facts to support the medical necessity of services provided will also be part of your role. You will create and maintain spreadsheets of open accounts, work directly with plan contacts to exchange data, identify root causes of issues, and reconcile data to confirm resolution. Tracking outcomes of requests for payment to ensure timely identification of additional actions needed will be essential, as well as reconciling and updating business systems and reports with findings and formalizing appeal documents required for follow-up action.

Responsibilities

• Meet and maintain production and quality standards defined by department policies and procedures.
• Review and analyze managed care balances related to short payments, denials, or those aged with no response.
• Evaluate authorization, coding, billing, and correspondence to identify underlying issues and determine the best course of action to collect.
• Compile detailed written appeal documents outlining position for payment.
• Identify and report payment and denial trends for assigned payors.
• Interact directly with the Department Clinical Team to obtain pertinent clinical facts needed to support medical necessity of services provided.
• Create and maintain spreadsheets of open accounts.
• Work directly with plan contacts to exchange data, identify root causes of issues, and reconcile data to confirm resolution.
• Track outcomes of requests for payment to ensure timely identification of additional actions needed.
• Reconcile and update business systems and reports with findings and formalize appeal documents required for follow-up action.

Requirements

• High School Diploma or Equivalent (Required)
• Two (2) years experience working in a hospital/physician business office, managed care collections, or managed care claims environment required.
• Detailed knowledge of government and managed care insurance terminology and reimbursement methodologies.
• Knowledge of federal and state regulations and laws/statutes related to payment for medical services.
• Knowledge of proper billing and coding of hospital services.
• Ability to formulate and write formal business communications.
• Intermediate knowledge of Microsoft Word and Excel.