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

Memorial Healthcare System; Florida; On-site; USD 42,000 - 62,000; Full time

Job summary

Memorial Healthcare System in Miramar, FL seeks a Billing Denials Specialist to review and analyze denials and short payments from insurance plans to determine the best plan for resolution. You will ensure actions comply with payor contracts, billing guidelines and federal/state laws.

Responsibilities include meeting production and quality standards, compiling appeal documents, tracking outcomes, coordinating with clinical teams, and reporting denial trends to management.

Qualifications

• Two (2) years experience working in a hospital/physician business office, managed care collections or managed care claims environment required.
• Must have knowledge of government and managed care insurance terminology and reimbursement methodologies.
• Knowledge of federal and state regulations and laws related to payment for medical services.
• Must be able to formulate and write formal business communications.
• Intermediate knowledge of Microsoft Word and Excel.
• Must demonstrate ability to make independent decisions.

Responsibilities

• Review and analyze denials and short payments to determine best plan for resolution.
• Ensure action is taken in accordance with payor contracts and laws.
• Prepare appeal documents and track outcomes.
• Interact with Clinical Team to obtain necessary clinical facts.
• Maintain and reconcile data in business systems.
• Identify payment/denial trends and report to management.

Skills

Accountability

Accuracy

Customer service

Managed care

Appeals

Trending

Problem solving

Communication

Teamwork

Workload management

Education

High School Diploma or Equivalent

Job description

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.
SummaryReviews and analyzes denials and short payments received from insurance plans to determine best plan for resolution. Takes action required to obtain payment in accordance with the terms of payor contract, applicable billing guidelines and/or Federal and State laws.
ResponsibilitiesResponsible to meet and maintain production and quality standards defined by department policies and procedures.
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 issue and determine best course of action to be taken to collect. Compiles detailed written appeal document outlining position for payment.
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.
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.
Responsible for identifying and reporting to Management payment and denial trends for assigned payors.
CompetenciesACCOUNTABILITY, ACCURACY, CUSTOMER SERVICE, MANAGED CARE COMPLIANCE APPEALS AND TRENDING, PROBLEM SOLVING, RESPONDING TO CHANGE, STANDARDS OF BEHAVIOR, TEAM WORK, WORKLOAD MANAGEMENT
Education And Certification RequirementsHigh School Diploma or Equivalent (Required)
Additional Job InformationComplexity of Work: Requires critical thinking and effective communication skills. Must be able to demonstrate ability to make independent decisions. Requires detailed knowledge of government and managed care insurance terminology and reimbursement methodologies. Must have knowledge of federal and state regulations and laws/statutes related to payment for medical services. Requires knowledge of proper billing and coding of hospital services. Must be able to formulate and write formal business communications. Intermediate knowledge of Microsoft Word and Excel. Required Work Experience: Two (2) years experience working in a hospital/physician business office, managed care collections or managed care claims environment required.
Working Conditions And Physical Requirements

• Bending and Stooping = 40%
• Climbing = 0%
• Keyboard Entry = 80%
• Kneeling = 0%
• Lifting/Carrying Patients 35 Pounds or Greater = 0%
• Lifting or Carrying 0 - 25 lbs Non-Patient = 40%
• Lifting or Carrying 2501 lbs - 75 lbs Non-Patient = 0%
• Lifting or Carrying > 75 lbs Non-Patient = 0%
• Pushing or Pulling 0 - 25 lbs Non-Patient = 40%
• Pushing or Pulling 26 - 75 lbs Non-Patient = 0%
• Pushing or Pulling > 75 lbs Non-Patient = 0%
• Reaching = 0%
• Repetitive Movement Foot/Leg = 0%
• Repetitive Movement Hand/Arm = 60%
• Running = 0%
• Sitting = 60%
• Squatting = 0%
• Standing = 60%
• Walking = 60%
• Audible Speech = 80%
• Hearing Acuity = 80%
• Smelling Acuity = 0%
• Taste Discrimination = 0%
• Depth Perception = 60%
• Distinguish Color = 60%
• Seeing - Far = 60%
• Seeing - Near = 60%
• Bio hazardous Waste = 0%
• Biological Hazards - Respiratory = 0%
• Biological Hazards - Skin or Ingestion = 0%
• Blood and/or Bodily Fluids = 0%
• Communicable Diseases and/or Pathogens = 0%
• Asbestos = 0%
• Cytotoxic Chemicals = 0%
• Dust = 40%
• Gas/Vapors/Fumes = 0%
• Hazardous Chemicals = 0%
• Hazardous Medication = 0%
• Latex = 0%
• Computer Monitor = 80%
• Domestic Animals = 0%
• Extreme Heat/Cold = 0%
• Fire Risk = 0%
• Hazardous Noise = 0%
• Heating Devices = 0%
• Hypoxia = 0%
• Laser/High Intensity Lights = 0%
• Magnetic Fields = 0%
• Moving Mechanical Parts = 0%
• Needles/Sharp Objects = 0%
• Potential Electric Shock = 0%
• Potential for Physical Assault = 0%
• Radiation = 0%
• Sudden Decompression During Flights = 0%
• Unprotected Heights = 0%
• Wet or Slippery Surfaces = 0%

ShiftDays
Disclaimer: This job description is not intended, nor should it be construed to be an exhaustive list of all responsibilities, skills, efforts or working conditions associated with the job. It is intended to indicate the general nature and level of work performed by employees within this classification.
Wages shown on independent job boards reflect market averages, not specific to any employer. We encourage candidates to talk to their Memorial Healthcare System recruiter to discuss actual pay rates, during the hiring process.
Memorial Healthcare System is proud to be an equal opportunity employer committed to workplace diversity.
Memorial Healthcare System recruits, hires and promotes qualified candidates for employment opportunities without regard to race, color, age, religion, gender, sexual orientation, national origin, veteran status, disability, genetic information, or any factor prohibited by law.
We are proud to offer Veteran's Preference to former military, reservists and military spouses (including widows and widowers). You must indicate your status on your application to take advantage of this program.
Employment is subject to post offer, pre-placement assessment, including drug testing.
If you need reasonable accommodation during the application process, please call 954-276-8340 (M-F, 8am-5pm) or email [e-mail]