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Process appeals from investigation to resolution according to CMS regulations and department policies and procedures, and within the timeliness standards. Collaborate with Appeals mJessicager 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
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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