Process appeals from investigation to resolution according to CMS regulations and department policies and procedures, and within the timeliness standards. Collaborate with Appeals manager and subject matter experts within the organization to obtain benefit and/or clinical opinions/interpretations of complex cases. Review inpatient and outpatient medical records for completeness and categorization of administrative or clinical appeal Coordinate with internal departments, external customers and delegated entities to gather additional documentation required to make an appropriate decision within the timeliness standards. Document all information related to the processing of appeals in Facets. Code diagnoses, procedures Remains current with the coding and processing of records to assure timely coding. Assures that the proper documentation is available in the medical record prior to coding. Enters codes for each provider and assures that the record is complete to assure that it is accurately abstracted. Follows through to assure the coding is finalized and a claim has been generated. Utilizes the available automated systems to achieve peak efficiency and accuracy
Acts as a resource or “lead” for all processor positions by answering questions, providing assistance, conducting training, and providing back-up for other positions as necessary. Processes medical, dental and/or hospital claims; processes complex claims independently. Provides customer service by responding to and documenting telephone and/or written inquiries. Meets quantity and quality claims processing standards. Performs pre-authorizations, audits files, requests check tracers and stop payments, and assists with researching and preparing appeals, as applicable. Maintains current knowledge of assigned Plan(s) and effectively applies knowledge in the payment of claims, customer service and all other job functions. Handle special duties and higher level, more complex functions (i.e. third party liability/subrogation, PPO updates, etc.) as assigned. Provide telephone and in-person support to over 200 end users, troubleshooting, diagnosing, resolving, and documenting hardware, software, and network related technical issues. Create, respond to, escalate, and close tickets. Track all outstanding tickets, working closely with Tier II Technician to ensure any problems are resolved in timely manner. Document all technical issues. Highlight steps taken to remediate problems
Responsible for financially securing the account, which includes Insurance Verification & Notification when not completed by PAS and securing the authorization number or written approval (TAR, etc.) concurrently throughout the patient stay. Complete Insurance Verification and initial Authorization request when insurance is discovered on Uninsured patients. The Patient Financial Assistant is responsible for providing timely insurance verification, authorization, CCS coordination, and the Medi-Cal TAR process for all inpatient accounts.
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