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

Memorial Healthcare System - Miramar, FL

Full-time

Miramar, FL

Hospitals

About the position

The position involves reviewing and analyzing denials and short payments from insurance plans to determine the best resolution strategy. The role requires taking necessary actions to obtain payments in accordance with payor contracts and applicable laws, ensuring compliance with billing guidelines.

Responsibilities

• Tracks outcomes of requests for payment to ensure timely identification of additional actions needed.
• Reconciles and updates business system and reports with findings and formalizes appeal documents required for follow up action.
• Reviews and analyzes managed care balances related to short payments, denials or those aged with no response.
• Evaluates the authorization, coding, billing and correspondence to identify underlying issues and determine the best course of action to collect.
• Compiles detailed written appeal documents outlining position for payment.
• Responsible for meeting and maintaining production and quality standards defined by department policies and procedures.
• Identifies and reports to Management payment and denial trends for assigned payors.
• Interacts directly with Department Clinical Team as needed to obtain pertinent clinical facts needed to support medical necessity of services provided.
• Creates and maintains spreadsheets of open accounts.
• Works directly with plan contacts to exchange data, identify root causes of issues and reconcile data to confirm resolution.

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.