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Fresenius Medical Care North America Associate Operations Claim Appeal Specialist in Waltham, Massachusetts

Job ID 21000P6J

Available Openings 1

PURPOSE AND SCOPE:

Assists in evaluating and responding to limited scope requests from patient primary insurance payors. In compliance with State and Federal laws, assists in administering patient primary insurance claims that were denied reimbursement and assists in initiating the next appeal step for Medicare, QIC or ALJ Hearing processes consistent with the requirements specified by the applicable payor appeal processes as outlined in the provider manual. Assists in monitoring, investigating and responding to payor audit requests. Adheres to company, regulatory and compliance program policy requirements.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

  • Under close supervision and in accordance with State and Federal laws, assists with the identification, investigation and resolution of limited scope claims under review, returned, disputed, or denied by a payor (e.g. Blue Cross Blue Shield or Medicare).

  • Performs reviews and analyses to determine why a claim is under review, in dispute, or was denied.

  • Confirms requests for patient information meets applicable HIPAA requirements before information is shared.

  • Assists in the assessment of patient records and coordination with various internal departments ensuring all appropriate documentation is obtained in order to respond to audit requests appropriately. Obtains copies of the medical and billing records as needed.

  • Reviews information obtained to identify discrepancies and anomalies, determining if services were properly documented and properly billed.

  • Documents any findings resulting from the claim review. Works with supervisor to determine if a remedy is available to address the finding. If a remedy is appropriate, works with client to implement remedy according to all applicable external requirements and internal policies.

  • Assists with the identification of any repayments.

  • Assists in drafting, submitting and tracking actions on appeal letters and other communication with medical payors or agencies on behalf of the company.

  • Utilizes and maintains internal databases to track the status of claims in review, in dispute, denied and any outstanding appeals.

  • Assists with analyzing and trending claim data to help develop appeals strategies for specific payors and identify any systemic issues.

  • Collects data from record reviews, denials, and appeals, and notifies supervisor of any identified deficiencies in controls.

  • Assists with the generation of monthly reports to communicate to management and division operations regarding the status of claim reviews, appeals, and repayments.

  • Organizes all work files including claim review work papers, claim response packages, communications to external payors, generated reports, worksheets, databases to ensure transparency and accessibility by other department members and ensure proper records management procedures are followed.

  • Responds to limited scope inquiries and/or reports of billing concerns, noncompliance with company policy and procedure.

  • Assists with ad hoc projects relating to company self-monitoring programs and other identified medication utilization/billing issues that require further review and possible audit.

  • Ensures privacy and security requirements and protocols are followed to protect individual medical records and other personal health information, and that destruction of any records is completed in compliance with company policy.

  • Learns and maintains knowledge of:

  • Health insurance appeals and provider dispute resolution processes, applicable clinical guidelines, and health payor coverage policies in order to effectively prepare claim packages for First Level Appeals and Redetermination Reviews.

  • All the necessary clinical and billing information required for an appeal including: Physician orders, treatment records, progress notes and other internal and external requirements for documentation of medical necessity.

  • Claim information, including required condition codes, value codes, HCPC codes, and other billing requirements.

  • Operational and billing policies, practices, and references related to ESRD regulations.

  • Other related duties as assigned.

PHYSICAL DEMANDS AND WORKING CONDITIONS :

  • The physical demands and work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Day to day work includes desk and personal computer work and interaction with patients, facility staff and physicians.

  • Travel to Regional, Divisional and Corporate meetings may be required.

EDUCATION:

  • Bachelor’s Degree or equivalent experience and education required.

EXPERIENCE AND REQUIRED SKILLS :

  • Bachelor’s Degree with 0-2 years’ directly related experience; or equivalent directly related work experience and education required.

  • Directly related healthcare regulatory & reimbursement experience preferred.

  • Fundamental knowledge of billing and reimbursement in Medicare Part A & B, Medicaid, and Commercial preferred.

  • Experience in ESRD billing and reimbursement preferred.

  • Strong customer service, communication skills (written and verbal), and excellent organizational ability.

  • Effective problem solving skills and strong attention to detail.

  • Clinical knowledge preferable but not essential.

  • Proficient with PCs and Microsoft Office applications.

EO/AA Employer: Minorities/Females/Veterans/Disability/Sexual Orientation/Gender Identity

Fresenius Medical Care North America maintains a drug-free workplace in accordance with applicable federal and state laws.

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