Identifies potential revenue lost by working through the review of Research and Denial accounts, comparing clinical information to standard of care registration, billing and collection of services. This position will provide a methodology by which the research documentation and denial documentation would alleviate the rejection or denial. This roll will employ process improvement for policies within the department. Ensures the research support and denial support is based on policy as it relates to both the clinical and hospital billing assignments. Provides education, as needed or works directly with clinical professionals on documentation dynamics related to billing processes and denial reduction.
Reviews medical denial cases and researches information to identify medical necessity and no authorization denial prevention.
Remains knowledgeable of clinical research criteria-specific guidelines and billing requirements.
Remains knowledgeable of the state and federal processes.
Ability to research CMS, as well as all other payer policies and procedures to utilize supporting documentation for bill submissions.
Submits necessary materials to validate and maintain an accurate database of clinical research cases and not medically necessary, no authorization and untimely filing denials.
Tracks and reports changes and delays that affects clinical research and denial cases.
Develops and implement the most effective approach for obtaining reimbursement for specific clinical research cases and denials.
Acts as a resource person for management and research coordinators as well as denial reporting.
Reviews and interprets reports related to clinical research and denial management documentation improvement initiatives, then applies this information as needed.
Communicates and presents, in a formal manner, the results of reports to stakeholders and operations.
Helps identify problems, offers solutions, and participates in their resolution.
Reviews medical record documentation to support billing and uses both written and verbal communication to enhance documentation for support services rendered.
Evaluates and interprets analyses and provides summary reporting.
Effectively communicates findings with leadership.
Identifies and compiles data from multiple sources to produce requested analysis to support improvement initiatives.
Measures changes and trends.
Works closely with all levels of staff to determine analytic and reporting needs which ensures that requested information is created accurately and in a timely manner.
Reports assigned project progress and activity as required.
Attends and participates with appropriate registration, billing, collections and denial workgroups as directed.
Work is typically performed in an office environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. *Relevant experience may be a combination of related work experience and degree obtained (Associate's Degree = 2 years; Bachelor's Degree = 4 years).
Focus on professional denials investigation and denials mitigation preferred.
CPC Certificate a PLUS.
High School Diploma or Equivalent (GED)- (Required)
Minimum of 5 years-Relevant experience* (Required)
Certification(s) and License(s)
OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities. KINDNESS: We strive to treat everyone as we would hope to be treated ourselves. EXCELLENCE: We treasure colleagues who humbly strive for excellence. LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow. INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation. SAFETY: We provide a safe environment for our patients and members and the Geisinger family We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners.* Perhaps just as important, from senior management on down, we encourage an atmosphere of collaboration, cooperation and collegiality. We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.
We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.
At Geisinger, our innovative ideas are inspired by the communities we serve – like our Fresh FoodFarmacy, a program that delivers life-saving healthy alternatives to patients with diabetes. With additional tools like our MyCode Community Health Initiative, one of the first health system genome sequencingprograms, and our new asthma app suite that we developed in partnership with AstraZeneca, it’s no wonder we’re ranked one of the Top 5 Most Innovative Healthcare Systems by Becker's Hospital Review. We continually work towards continuous improvement in a culture where everyone has a voice and firmly believe that better begins with all of us.Founded more than 100 years ago, Geisinger serves more than three million residents throughout central, south-central and northeastern Pennsylvania and southern New Jersey. Our physician-led system is comprised of 30,000 employees, including 1,600 employed physicians, and consists of 13... hospital campuses, the Geisinger Health Plan, Geisinger Commonwealth School of Medicine and two research centers. What you do at Geisinger shapes the future of health and improves lives – for our patients, communities, and you.