Appeals Coordinator for Skilled Nursing Services Job at Athens
ESSENTIAL DUTIES AND RESPONSIBILITIES
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- Develops, interprets and implements operational requirements as it relates to the process of tracking requests for medical records from CMS Recovery Program (RAC), CMS Medicaid Integrity Program and all other payer reviews for medical necessity and RUG validation.
- Ensures day-to-day oversight of investigation, remediation and reporting of complaints and reviews as it relates to denials and appeals of claims.
- Assumes the administrative authority, responsibility and accountability of directing the RAC validation reporting activities and programs of assigned divisions.
- Accountable for daily coordination, monitoring and direction of RAC and all other related activities.
- Provides education as needed for new associates to ensure that the organization is prepared for RAC audits and other similar audits.
- Coordinates response to audit requests, challenges questionable determinations and assists in filing timely appeals.
- Audits and analyzes third party payer reimbursement to ensure proper remuneration.
- Uses sound judgment and discretion when communicating findings related to appeals. When necessary, will obtain authorization for release of sensitive and confidential information.
- Oversees and implements departmental processes for review of prospective, concurrent or retrospective medical records of denied services for medical necessity.
- Makes administrative appeal determinations when indicated and properly sets up case files for clinical review when needed.
- Reviews the organization’s procedural guidelines periodically, at least annually, and suggests changes, as necessary, to provide continued compliance with current regulations.
- Performs other duties as necessary to ensure the success of the System.
- Knowledge of principles and practices of accounting and finance administration.
- Knowledge of management and organizational concepts.
- Considerable knowledge of healthcare and long term care organizations and their structure.
- Through knowledge of laws, rules, and regulations governing managed care, Medicare, Medicaid, and other governmental healthcare reimbursement program.
- Ability to interpret and apply state and federal laws, rules and regulations governing financial standards.
- Ability to effectively communicate and present information in a clear and concise manner, both orally and in writing.
- Ability to maintain effective working relationships with associates, department heads, administrators, member organization presidents, and the general public.
- Bachelor’s Degree required.
- Minimum of two years of experience in a reimbursement capacity in a hospital or long-term care center.:
Please Note :
chrismaxcer.com is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, chrismaxcer.com provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, Site.com is the ideal place to find your next job.