Job Summary Performs post payment clinical auditing in defense of hospital charges. This position audits patient records to evaluate medical necessity and charge capture in an effort to minimize hospital losses; conducts requested audits to ensure consistency between medical records documentation and billing statements on patient accounts; submits appeals to payers on patient account denials when appropriate; reviews medical records and other patient documents as needed to support hospital departments; and communicates findings to appropriate departments
Responsible for conducting reviews and responding to insurance denials. Writes concise, factual letters and provides medical record documentation to support appeal. Effectively communicates verbally with external and internal customers to ensure argument for appeal is clearly presented. Prioritizes and organizes own work to meet appeals and grievance deadlines. Responsible for the denials process, including subsequent appeal to health insurance.
Performs charging and documentation audits on selected accounts as part of Scottsdale Healthcare's audit and compliance plan. Reviews for completeness of documentation based on charges. Reviews charges for completeness and accuracy based on documentation. Determines if charges supported by documentation have been missed.
Maintains timely data entry into MIDAS denial tracking software and workflow processing, to ensure an accurate denial log of all cases.
Demonstrates awareness of departmental charging procedures and serves as a liaison between department managers and Patient Financial Services. Demonstrates awareness of payer specific reimbursement methodologies and payer specific policies and procedures regarding charging, coding, billing, claim processing, and dispute resolution to assist patients and employees of Scottsdale Healthcare. Assists and educates patient representatives regarding pricing questions and item descriptions as needed to increase efficiency.
Performs patient inquiry audits as requested. Provides audit results and written explanation of line items (if needed) to the patient representative or supervisor. Meets with patients and corresponds electronically, telephonically, and by mail to assist with understanding of services, pricing, and the myriad of payer specific policies and procedures that impact them financially.
Internal Number: 2018-14127
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Welcome to HonorHealth.
We are a non-profit, local healthcare organization known for community service and outstanding medical quality. Our organization encompasses five acute care hospitals with approximately 10,500 employees and 3,100 volunteers, urgent care centers, clinical research, medical education, an inpatient rehabilitation hospital, an Accountable Care Organization, two foundations, and extensive community services.