Reimbursement Analyst Resume Samples

Description :

1. Conducting researches and analysis to detect claim problems and recommending the viable solution, interim alternatives, and documentation of processing irregularities.
2. Performing operational and procedural audits directed towards assessing the accuracy of specific reimbursement systems for participating acute care hospitals and institutional providers.
3. Reconciling the complex hospital and institutional accounts which includes research, analysis, adjustments, facility claim processing and recovery of the overpayment.
4. Performing the root cause analysis regarding discrepancies related to claims processing.
5. Identifying and initiating the resolution of critical issues with divisions and departments within a horizon that impact the facility's business.
6. Developing and preparing the trend reports, including presentation of findings and audit results to both internal and external audiences.
7. Recommending and developing the corrective action plans to remedy facility billing/educational issues or systemic problems including internal workflows and training recommendations.
8. Researching, analyzing and respond to the department of insurance complaints and executive inquiries as they relate to facility claims.

Experience

10+ Years

Level

Consultant

Education

Diploma

Description :

1. Maintaining Charge Description Master (CDM) and pertinent regulations and policies, ensuring all data elements are accurate and comply with the payor and regulatory requirements (i.e. Ncci/modifier 59, medical necessity, correct coding initiative, an outpatient code editor, inpatient code editor, etc.).
2. Handling appropriate CDM additions, modifications, deletions and reactivations in the hospital billing systems.
3. Creating and maintaining the charge and coding related billing edits in the hospital system for outpatient and inpatient claims.
4. Working with Patient Financial Services (PFS) to re-bill and/or appeal denied or disputed claims that arise from billing deficiencies.
5. Reviewing implant and high-cost drug accounts to ensure charges are accurate and pricing is in accordance with managed care contract obligations.
6. Providing education, documentation guides and training to all clinical departments, patient financial services, medical records and other revenue producing departments as needed to promote appropriate charge capture processes and improve understanding of the documentation requirements for specific charge activity.
7. Identifying charging, coding or clinical documentation issues, patterns of rejections, partial denials or denials from third-party payers and work with ancillary departments to resolve issues, decrease denials, and notify appropriate leadership.

Experience

7-10 Years

Level

Senior

Education

BS

Description :

1. Ensuring compliance with state and federal laws and regulations for Medicare, and Medicaid using in-depth knowledge of coding, clinical documentation, reimbursement methodologies, and fraud and abuse laws.
2. Performing audits and assigning CPT, HCPCS, and ICD-10 codes to improperly coded UB04 and CMS 1500 claims while documenting all details for reporting to the director of revenue integrity for his system correction.
3. Training and supervising the A/R representatives daily, create training manuals for new hires, collaborate with other departments as needed for training, and meet with provider representatives on escalated issues.
4. Performing weekly, monthly, and annual reporting to director level and above to support daily functions based on operational needs to include, but not limited to productivity reporting, claims reconciliation, cost reporting, report writing to query underpaid CPT/HCPCS procedure code, revenue codes, diagnosis code and any other variables as needed.
5. Performing analysis and drawing inferences of gathered data to evaluate and investigate profitable solution within all required compliance standards to include trending analysis to identify root causes, delays and claim denials.
6. Providing the analytical and managerial support in all capacities within patient financial service to streamline processes by developing and implementing strategic procedures to effectively execute the workflow.
7. Effectively communicating with peers across the revenue cycle organization and provider representatives to ensure timeliness, accuracy, and development of ongoing processes for improvement.

Experience

5-7 Years

Level

Executive

Education

MS

Description :

1. Researched accounts for adjustments, Medicare, insurance patient payments retractions, refunds rebilling.
2. Updated patient account records in Artiva, HCA host RRT to identify actions taken on the account.
3. Updated accounting discrepancies on patient account records e-mailed accounting for updates to their records.
4. Researched handled correspondence through RRT, ARTIVA, CRT, CRWT, e-request, on base, HCA host e-mails to assist orange park appeals analysts.
5. Worked weekly medicare unpaid claims report, to research resolve discrepancies in Artiva, HCA host, Concuity.
6. Reported regularly to Lead Analyst or Supervisor on payer trends identified.
7. Prepared Medicare and Medicaid annual cost report filings and audits for nursing homes, hospice, and home health.
8. Utilized and applied the appropriate regulations in order to assure compliance in payment practices.

Experience

10+ Years

Level

Consultant

Education

Certification

Description :

1. Verifying, calculating, analyzing, strategizing and projecting the reimbursement rates.
2. Preparing and analyzing ACLDS annual cost reports including article 28 AHCF.
3. Assisting in the development and implementation of the annual operating budget with respect to revenue assumptions and methodologies.
4. Advising the Program Directors, CFO in fiscal planning and decisions affecting currently operated programs, as well as new programs under consideration.
5. Maintaining contacts with third parties and attend relevant conferences to assure keeping abreast of rate methodology changes and to obtain funding due to ACLD.
6. Preparing and submitting the application for new or adjusted rates and work with funding sources for optimum results.
7. Performing special projects including final expenditure reports for new projects, etc.
8. Assisting/mentoring the finance staff in preparation and analysis of financial statements, general ledger, grants and special projects.
9. Reviewing and analyzing the budget to actual variances, present findings to Program Directors.

Experience

7-10 Years

Level

Senior

Education

BS

Description :

1. Identifying trends and payments that are inconsistent with contract rates.
2. Creating spreadsheets of trends of underpaid claims due to various issues to present to insurance representatives.
3. Advising the team and the credentialing team of the TIN, NPI and provider profile issues that are causing underpayments.
4. Accounts receivable, follow-up, charge entry and authorization review for inpatient and outpatient services.
5. Responsible for hospital billing and clinical trial cases and well as skilled nursing charges.
6. Daily use of encoder-pro and e-paces as well as all managed care and Medicare websites.
7. Responsible for insurance refund requests and Medicare audits and insurance take backs on paid and unpaid accounts.
8. Reviewing the medical records and documentation to assure that all service rendered are captured on the billing charge forms.
9. Adding required modifiers as needed to assure that providers are reimbursed.

Experience

10+ Years

Level

Consultant

Education

Certification

Description :

1. Responsible for being aware of the current department policies and procedures.
2. Effectively documented actions and results providing clear written communication, appeal letters (in appropriate locations) and within the organization.
3. Answered phones and responded to inquiries or problems in a professional and courteous manner within three rings.
4. Assisted patients/clients with billing and coding, insurance benefit investigations, prior authorization, and appeals inquiries.
5. Managed patient cases and interact with patients, healthcare providers, payers, and pharmaceutical and biotech manufacturer sales teams.
6. Identified and assessed the patient-specific insurance coverage options for client specific products.
7. Reviewed patient data to prepare current year and retrospective Medicare bad debt, managed Medicare bad debt, initial and pre-audit disproportionate share listings to ensure all clients are properly reimbursed on the cost report.

Experience

2-5 Years

Level

Entry Level

Education

College

Description :

1. Worked to resolve moderately to highly complex billing, claim processing, and reimbursement issues.
2. Maintained AR in assigned queues, actively working with insurance carriers on open ar to ensure timely follow up research account specifics to complete necessary actions.
3. Contacted insurance payers and providers via telephone, email, or correspondence on aged/delayed claims for resolution.
4. Communicated with all parties in a professional manner and provide explanations regarding the account (s).
5. Ensured confidentiality of all patient accounts by following HIPAA guidelines.
6. Responsible for being aware of the current department policies and procedures.
7. Reported regularly to lead analyst or supervisor on payer trends identified.
8. Effectively documented actions and results providing clear written communication, appeal letters (in appropriate locations) and within the organization.

Experience

2-5 Years

Level

Entry Level

Education

CPT

Description :

1. Screening the self-pay clients to find a state-funded medical program to help pay for their hospitalization.
2. Assisting the clients with their new and pending applications for social security.
3. Typing, filing, faxing, and photocopying the documents, completing applications.
4. Working closely with doctors to obtain necessary medical forms completed.
5. Running monthly reconciliation reports for all active and missing accounts.
6. Running the weekly reports for crime victims, sexual assault, Medicaid spends down.
7. Registering the end of the month applications printed medical records, itemized bills.
8. Scheduling the daily appointments with patients in need to drop off supporting.
9. Traveling and managing the client accounts for six different hospital locations.

Experience

5-7 Years

Level

Executive

Education

Certification

Description :

1. Responsible for assisting the Russian speaking clients.
2. Promoted to reimbursement specialist position within seven months of service.
3. Managing and updating when necessary patients’ demographics using Salesforce software.
4. Reviewing the appropriateness of CPT/ICD 9 coding and determining if care provided corresponds to the charges submitted.
5. Responsible for obtaining initial and ongoing insurance/managed care benefits from insurance providers.
6. Gathering the pertinent information from insurance carriers, financial counselors, and other ancillary staff to make certain the patient is not financially obligated for services provided.
7. Responsible for receiving, responding to, and directing member phone calls.
8. Ensuring new client generation by responding to questions quickly and thoroughly to maximize customer satisfaction.
9. Verifying daily insurance eligibility and order contents for all DME orders to ensure maximum reimbursement for the company.

Experience

7-10 Years

Level

Senior

Education

Diploma