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Coding and Appeals Analyst in Knoxville, TN at TeamHealth

Date Posted: 8/17/2018

Job Snapshot

Job Description

Join a team of dynamic, results oriented professionals!

Named among “The World’s Most Admired Companies" by Fortune Magazine
Named among "America's 100 Most Trustworthy Companies" by Forbes magazine
Named among “Great Places to Work" by Becker’s Hospital Review

  • Benefit Eligibility (Medical/Dental/Vision/Life) the first of the month following 30 days of employment
  • 401K program (Discretionary matching funds available)
  • Employee Assistance Program
  • Dental plans & Vision plans
  • GENEROUS Personal time off
  • Eight Paid Holidays per year

JOB OVERVIEW:

This position is responsible for the review, analysis, research and completion of non-routine appeals that may require a clinical summary to support the necessity of the service provided. Ensure timeliness, quality and efficiency to comply with payer appeal requirements. This position will also provide support and coordination of special appeal projects as requested. 

ESSENTIAL FUNCTIONS: 

  • Evaluate payer responses and write justification for appropriate payment. Responses may require clinical details to demonstrate medical necessity for the service provided as well as justification for the CPT code assignment. 
  • Obtain necessary documentation in preparation of the appeal response. Responsible for completing and filing the response to the payer. 
  • Prepare requested reports by collecting, analyzing and summarizing results of appeals as well as documentation of lessons learned. 
  • Provide analysis and documentation of on-going appeals in Excel format. Create trend reports and maintain these reports in this same format. 
  • Assist with the development and implementation of process documents when pilot appeal projects are found to be successful. Assist with education of the favorable appeals process with the billing centers. 
  • Effectively interact and communicate with billing centers and other HCFS associates concerning payer appeal content and clinical education as needed. 
  • Stay current on relevant coding and billing regulations, specifically as they relate to coding and billing for emergency department, anesthesiology, acute care services, post-acute care services, and clinic services. 
  • Develop and maintain knowledge of relevant coding laws, rules and regulations of governmental and non-governmental payers. 
  • Maintain timely communication with the Director of Health Plan Claim Reviews and Audits on concerns that may be observed regarding payer policy, documentation or coding. 
  • When requested, assist the Chief Medical Officer, Coding Policy, with the clinical review and preparation of complex payer appeal responses for all lines of business. 
  • Create and maintain an electronic archiving process to store non-routine appeals and results. 
  • Assist the Director of Health Plan Claim Reviews and Audits to create and provide education to the billing centers. Assist in the creation of sample letters of appeal for the billing center’s use. 
  • Assist the Director of Health Plan Claim Reviews and Audits in the organization and collation of special projects that may arise from legal, compliance, disputes and operations. Provide clinical review and preparation of materials for these projects. 
  • Ensure confidentiality and adherence to HIPAA regulations of patient PHI in payer and company correspondence. 
  • Ensure that quality standards are being adhered to, deadlines are met, and HCFS policies and procedures are being followed. 
  • Assist with special studies and the monitoring of payer trends in rejecting claims for service as well as lowering the level of a claim and paying a lesser rate. This may include payer policy research as well as the reviewing of claims that may trigger the rejection. 
  • Assist with daily operations and other duties as assigned.

Job Requirements

PHYSICAL AND ENVIRONMENTAL DEMANDS 

The physical and environmental demands of this position are as follows:  

  • Job is performed in a well- lighted, modern office setting.
  • Occasional standing/bending
  • Occasional lifting/carrying (20 pounds or less)
  • Limited travel locally and nationally with occasional overnight stays away from home.
  • Moderate stress
  • Prolonged sitting
  • Prolonged work on a PC/Computer 

This position may require manual dexterity and/or frequent use of the computer, telephone, 10-kay, calculator, office machines (Copier, scanner, fax) and/or the ability to perform repetitive motions and/or meet production standards to comply with the essential functions. Also, may require physical and/or mental stamina to work overtime, additional hours beyond a regular schedule and/or more than five days per week. 

JOB QUALIFICATIONS 

The job qualifications for this position are as follows: 

  • Clinical experience preferred (RN, LPN, etc.)
  • Medical coding experience required, minimum three years
  • Coding certification required within one year (CPC, CCS-P, RHIT, RHIA or equivalent).
  • Billing and AR experience a plus
  • Previous experience with medical record appeals, chart audits, utilization review and quality assurance experience preferred
  • Experience in applying coding policy, payer policy, reimbursement procedures, and standards in medical billing environment
  • Excellent knowledge of CPT coding, ICD-10 coding and other industry standard coding tools.
  • GE IDX and OnBase proficiency required willingness to learn other billing center processes mandatory.
  • Intermediate to advanced proficiency in Microsoft Word and Excel.
  • Ability to multitask and meet deadlines.
  • Ability to handle confidential data.
  • Excellent communication skills both verbal and written
  • Ability and willingness to present educational programs to small audiences.
  • Excellent organizational skills
  • Ability to work independently while adhering to instructions and established policies and procedures with minimal supervision.
  • Willingness to participate in education programs to increase skill level.
  • Willingness to travel with overnight stays away from home as required 

Cooperative, positive, courteous and professional behavior and conduct is an essential function of every position. All employees must be able to work with others beyond giving and receiving instructions. This includes getting along with co-workers, peers and management without exhibiting behavior extremes. Job functions may require personal leadership skills such as conflict resolution, negotiating, instructing, persuading, speaking with others as well as responding appropriately to job performance feedback from the supervisor. Additionally, the information contained in this job description has been designated to indicate the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and   qualifications required of employees assigned to this position.