Claims Review Analyst

General Summary

Supports the system in charge capture, coding accuracy, and claim denials management. Conducts reviews of claim denials and submits appeals. Performs a variety of functions including, but not limited to answering inquiries and researching third party payer policies and coding guidelines to optimize reimbursement for the system while ensuring compliance with applicable laws and regulations.

Duties and Responsibilities

Essential Functions:

• Consults with departments throughout the system on charge processes. Ensures appropriate use of CPT, HCPCS and ICD-10 codes as well as modifiers.
• Conducts reviews comparing medical record documentation to validate charge capture, medical necessity, and coding accuracy.
• Investigates and recommends action steps and works collaboratively with the department when coding and/or compliance issues are found.
• Identifies denial trends, billing errors, and determines root cause to prevent future denials.
• Investigates billing system errors, through help desk tickets and work queues, due to potentially inappropriate documentation, coding, medical necessity or charge entry. Communicates with departments, including Compliance to initiate steps for resolution.
• Investigates payer denials and institutes appropriate courses of action.
• Prepares detailed appeals and attends Medicare Administrative Law Judge (ALJ) hearings as necessary for Medicare
• Interacts with providers, managers, and staff in departments to ensure correct coding of claims.
• Maintains current knowledge of payer/insurance policies, rules and regulations, including state and federal guidelines.
• Demonstrates initiative and resourcefulness by communicating results of claims review activity to PCS and PFS Leadership.
• Serves as point person for department when assigned and consistently displays good judgment, decision making and independence in the role, with minimal guidance and supervision.
• Attends insurance update meetings, provides synopsis of bulletins and notifies affected areas.
• Requests coding edits in EPIC based on payer bulletins and/or policies.
• Assists leadership in PCS and PFS in the completion of routine assignments and special projects as needed.
• Approves and processes all PB fee schedule requests via Remedy Force.
• Creates and presents yearly ICD-10 and CPT changes.
• Presents education, training and feedback to providers, practice managers and staff.

Common Expectations:

• Adheres to established policies and procedures, objectives and quality assessment and safety standards.
• Enhances professional growth and development through participation in educational programs, current literature, in-services meetings and workshops.
• Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.