Medical Necessity Appeals Specialist - Nashville, United States - Integrated Oncology Network, LLC

Description

Partnering With Physicians To Provide Best In Class Patient Care

Founded in 2002, Integrated Oncology Network is committed to helping our physicians deliver the right care, at the right time and in the right setting. We strongly believe that preserving the independent practice of medicine where patients are cared for closer to home and surrounded by our dedicated clinicians yields better outcomes. By creating a care continuum between our clinicians, patients and their support networks we deliver an unparalleled approach to the patient's care journey.

The Medical Necessity Appeals Specialist is responsible for appealing denials with supporting medical justification to

overturn payer decisions resulting in claim payment and educate center/billing staff to prevent future denials.

Essential Functions:

• Logs, tracks, and processes appeals and grievances

•Conducts the medical review activities needed to resolve and process clinical appeals and claims.

•Understands and interprets applicable medical terminology, clinical procedures, regulations and policies. Construct effective appeal letters using medical justification to support appropriate reimbursement

•Reviews applicable medical records and assesses clinical data to investigate and resolve disputes over the medical necessity for services, approvals, pre-certifications, or other cases

•Prepares the documentation required for further medical review, hearings, and different appeal processes

•Sets up and maintains case files for each grievance and collects the information required by organizational policies and applicable regulations

•Conducts research and coordination needed to evaluate, process, respond to, and refer or close appeals

•Works closely with insurance carriers for reimbursement requirements/opportunities to ensure payment in challenging situations

•Identify denial and AR trends to address consistent issues

• Review and stay current with payer and regulatory requirements and communicate changes to team and leadership

•Support management with special projects and process improvements

•Work is generally independent and collaborative in nature

•Regular attendance and punctuality

•Perform any other functions as required by management

Qualifications and Education Requirements

•Minimum 5 years of experience in Revenue Cycle

•Education including RHIA, RHIT, CPC, CCS, or nursing degree

•Superior written and verbal communication skills

•Understanding of managed care contracts and fee schedules, including Medicare and Medicaid

•Experience reviewing patient medical records to review conditions of coverage

•Experience with computerized billing software, EMR, clearinghouses and interpreting paper and electronic EOBs

•Working knowledge of ICD-10, HCPCS, and CPT coding

Preferred Skills

•Bachelor's Degree preferred

•Experience with multiple billing systems and EMR

•Proficiency in CPT, HCPCS and ICD 9 and 10 coding

•Proficient in Microsoft Office to include Excel, Word, PowerPoint, and Outlook

•Oncology billing

Required Competencies

Ability to work in a team environment and enjoy multi-job functions. Strong Business and Organizational Competence. Exceptional Customer Service Skills. Strong functional Competence. Interpersonal Skill Competency. Stress Tolerance. Initiative. Adaptability. Accountability. Integrity. Self-Confidence. Time Management Skills with an emphasis on multi-tasking.

Physical Demands and work environment

The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Physical demands: Required job duties are essentially sedentary in nature, consisting of occasional walking, standing, lifting and/or carrying ten pounds maximum, seeing, speaking and hearing. Must be able to lift up to 25 pounds.

Work environment: Required job duties are normally performed in a climate-controlled office environment.