JOB SUMMARY

Responsible for validating dispute reasons following Explanation of Benefits (EOB) review, escalating payment variance trends or issues to NIC management, and generating appeals for denied or underpaid claims.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Validate denial reasons and ensures coding in DCM is accurate and reflects the denial reasons. Coordinate with the Clinical Resource Center (CRC) for clinical consultations or account referrals when necessary,
Generate an appeal based on the dispute reason and contract terms specific to the payor. This includes online reconsiderations.
Follow specific payer guidelines for appeals submission
Escalate exhausted appeal efforts for resolution
Work payer projects as directed
Research contract terms/interpretation and compile necessary supporting documentation for appeals, Terms & Conditions for Internet-enabled Managed Care System (IMaCS) adjudication issues, and referral to refund unit on overpayments.
Perform research and makes the determination of corrective actions and take appropriate steps to code the DCM system and route account appropriately.
Escalate denial or payment variance trends to the NIC leadership team for payor escalation

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

Intermediate understanding of Explanation of Benefits form (EOB), Managed Care
Contracts, Contract Language and Federal and State Requirements
Intermediate knowledge of hospital billing form requirements (UB-04)
Intermediate understanding of ICD-9, HCPCS/CPT coding, and medical terminology
Intermediate Microsoft Office (Word, Excel) skills
Advanced business letter writing skills to include correct use of grammar and punctuation

AR II Representative (Eastwood Site)

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