Job Description

Description

The Outpatient Resubmission Officer is responsible for ensuring that all eligible accounts are appealed within the designated payer timeframes. The position is also responsible for analyzing the root cause analysis of the denied claims and develop corrective action plan for resolution of denials.

?

Job Functions and Key Accountabilities:

Work proactively with Director RCM, Manager RCM, Coding staffs, and Pre-authorization staffs to develop measures to reduce the number of denials through research of denial trends. ?Analyses and categorizes denials based on the root cause findings and continually improves best practice methodology for denied claims recovery Acts as a resource when necessary for billing, pre-authorization and reimbursement issues and coding. ?Aware of current trends related to medical necessity, DRG and DOH Claims and Adjudication rules and coding guidelines Applying advanced knowledge of medical terminology, anatomy and physiology, treatment modalities, diagnostic test, medications Providing orientation and education to coders, pre-authorization co-coordinators, physicians and nurses based on Rejection Analysis. Excellent interpersonal skills while interacting with physicians, nurses and other staffs. Ensure high level of patient data confidentiality. Expertise in Diagnosis Related Grouping Utilizes tools available in 3M to ensure accurate coding. Ensure knowledge on deductibles, co-payments, co-insurance amounts, insurance exclusions and other policies of all insurances that Kanad Hospital is dealing with. Critical thinker with ability to perform root cause analysis, prepare and implement action plans and lead improvement initiative. Query physician for clarification and additional documentation prior to resubmission.4.14. Perform other related duties incidental to the work described herein.

Technical Competencies:

Evaluates and ensures that- all claims denied or underpaid inappropriately by payers are identified, appealed and reversed within the designated payer timeframes Effective physician query process prior to resubmission to obtain greatest possible diagnostic specificity and clinical documentation to accurately reflect the patient's condition. ?Providing education to the team based on the root cause analysis of denied claims. Ensures to reduce rejections and get the claim paid at the initial resubmission of claims. Advance knowledge in DRG assignment through retrospective review of medical record for all relevant clinical conditions/diagnosis and procedures.

Qualification

Education

: Degree in any related field preferably life science background. CPC (AAPC) certification will be a plus.

Experience

Experience

: Minimum of five (5) years Outpatient coding experience in any setting i.e., hospital, clinic, home health, or other related healthcare field is required. In addition to medical coding, knowledge of billing process will be a plus. Both inpatient and outpatient coding experience preferred.