Responsible for analyzing denials, trends, and process inefficiencies to develop actionable improvement plans. Ensure accurate billing and coding by reviewing charge queues, collaborating with care centers, and resolving claim discrepancies. Works closely with internal and external teams to address escalated claim issues, maintain compliance with payer policies, and support process enhancements to maximize reimbursement.


Principal Accountabilities:
 

Analyze trends in medical claim denials, reimbursement issues, and process-related challenges; translate findings into actionable improvement plans and projects. Assist with charge work queues for proper billing and coding, ensuring accurate charges are released to the billing company as needed. Collaborate with providers and practices to resolve claim discrepancies and initiate necessary corrections. Research and resolve claims not paid within industry standards, ensuring compliance with prompt payment regulations. Review and correct provider-related issues in the database, ensuring accurate information for claims processing. Engage with practices and billing vendor to review claims in the Request for Information (RFI) portal for refiling accuracy as needed. Review the Data Capture report for missing information or errors before claim submission, ensuring accuracy and coding compliance by cross-checking electronic medical record sources. Work closely and collaborate with internal teams (e.g., Coding & Compliance, Credentialing, Managed Care Contracting) and external teams (e.g., Billing Vendor, Insurance Payer Representatives) to resolve escalated claim-related issues. Review and verify accuracy of proposed guarantor and insurance refunds, collaborating with the billing vendor to resolve discrepancies and communicate approved refunds to Accounts Payable and Finance teams. Participate in weekly meetings with Billing teams to identify process issues and recommend improvements. Research and interpret insurance carrier billing or reimbursement policies to ensure compliance. Maintain payer portal attestations for the PCP organization, ensuring timely compliance every 90 days. Perform other duties as needed to support departmental and organizational goals.