Fresenius Medical Center Operations Claim Appeal Specialist in Waltham, Massachusetts

PURPOSE AND SCOPE:

Evaluates and responds appropriately to requests from patient primary insurance payers. In compliance with State and Federal laws, administers patient primary insurance claims that were denied reimbursement and initiates the next appeal step for Fair Hearing or ALJ Hearing processes consistent with the requirements specified by Medicare Appeal Processes as outlined in the provider manual. Monitors, investigates and responds to all Medicare Audit requests.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

  • In accordance with State and Federal laws, identifies, investigates and resolves claims under review, returned, disputed, or denied by either a commercial or a government payer (e.g. Blue Cross Blue Shield or Medicare).

  • Performs detailed review and analysis to investigate audit requests from Medicare Recovery Audit Contractors. Determines why a claim is under review, in dispute, or was denied. Coordinates with various internal departments ensuring all appropriate documentation is obtained in order to respond to audit requests appropriately.

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

  • Requests copies of the medical records and corresponding claims.

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

  • Documents any findings resulting from the claim review and determines 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.

  • Ensures necessary repayments are completed by the appropriate party for any identified payment discrepancies.

  • Interprets and understands health insurance appeals and provider dispute resolution processes, applicable clinical guidelines, and health payer coverage policies in order to effectively prepare claim packages for First Level Appeals, Reconsideration Reviews, Redetermination Reviews, Medicare Administrative Contractor Reviews (MAC), and final appeals. Submits claim packages to the Administrative Law Judge (ALJ) as necessary.

  • Understands all of 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.

  • Drafts, submits and tracks action on appeals letters, reconsideration and re-determination requests and other communication with medical payers or agencies on behalf of FMCNA.

  • Utilizes and maintains the internal database to track the status of claims in review, in dispute, denied and any outstanding appeals. Analyzes and trends claim data to help develop appeals strategies for specific payers and identify any systemic issues.

  • Collects, analyzes and investigates data from record reviews, denials, and appeals, identifying deficiencies in controls, performing trend analyses, and making recommendations for areas of improvement, specifically in documentation and billing practices that commonly result in incorrect or non-payment of services.

  • Generates and analyzes monthly reports to communicate to management and FMS division operations regarding the status of claim reviews, appeals, and repayments.

  • Serves as a resource and provides education and training to assist internal clients with requirements of:

  • Internal policies on documentation of medical necessity for services rendered.

  • Internal policies on medical claim review and management of documentation requests.

  • Medicare, Medicaid, and other payor requirements/regulations on billing and reimbursement of ESRD services.

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

  • Maintains current knowledge of operational and billing policies, practices, and references related to ESRD regulations.

  • Responds to inquiries and/or reports of billing concerns, noncompliance with company policy and procedure taking the appropriate actions as required.

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

  • Other duties as assigned.

Additional responsibilities may include focus on one or more departments or locations. See applicable addendum for department or location specific functions.

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. The position may require travel between assigned facilities and various locations within the community.

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

EDUCATION :

Bachelor’s Degree - concentration in Business or Healthcare preferred.

EXPERIENCE AND REQUIRED SKILLS:

  • Minimum 2 years related healthcare regulatory & reimbursement experience with a Bachelor’s Degree.

  • Minimum 4-5 years directly related healthcare regulatory & reimbursement experience with an Associate’s Degree.

  • Minimum 7 years directly related healthcare regulatory & reimbursement experience with a High School diploma.

  • Knowledge of billing and reimbursement in Medicare Part A & B, Medicaid, and Commercial

  • Experience in ESRD billing and reimbursement.

  • Must have 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.

  • Ability to analyze information obtained from the division’s clinical and financial databases and billing systems.

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