MSRDP Clinical Denials Management Specialist III - Surgical Billing Follow Up
Categories: Insurance / Billing
Department: MSRDP Team 4 Admin
Full/Part Time/PRN: Full-Time
This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information
Experience and Education
High School diploma or equivalent, Associates degree preferred, and six (6) years medical billing or collections experience. Two (2) years must include denial management and proven knowledge of billing/coding guidelines for complex E&M services, diagnostic studies, and/or minor surgical procedures that encompasses CPT and ICD-10 codes, modifiers, and payer specific rules. Experience involving complex diagnostic studies, endoscopic, interventional and/or surgical procedures preferred. Work requires experience in Medical Billing, Accounts Receivables, and/or Collections within a healthcare or insurance environment. Work requires knowledge of CMS 1500, ICD-10, and CPT coding. Requires working knowledge of Epic Resolute.
1. Review, research and resolve coding denials for complex diagnostic studies, endoscopic, interventional and/or major surgical procedures. This includes denials related to the billed E&M, CPT, diagnosis, and modifier. Denial types could include bundling, concurrent care, frequency and limited coverage. Prepare and submit claim appeals, based on payor guidelines, on complex coding denials. Identify denial, payment, and coding trends in an effort to decrease denials and maximize collections.
2. Contact payers, via website, phone and/or correspondence, regarding reimbursement of claims denied for coding related reasons. Interpret Managed Care contracts and/or Medicare and Medicaid rules and regulations to ensure proper reimbursement/collection.
3. Requires knowledge of carrier specific claim appeal guidelines. This includes Claim Logic, internet, and paper/fax processes. Requires proven analytical, and decision making skills to determine what selective clinical information must be submitted to properly appeal the denial. Requires proven knowledge of CPT and ICD-10 coverage policies, internal revenue cycle coding processes and the billing practices of the specialty service line. This position requires clear and concise written and oral communication with payors, providers, and billing staff to insure resolution of complex coding denials.
4. Requires the ability to read and interpret E&M notes, complex diagnostic study results, endoscopic and interventional results and/or major surgical operative notes. Based on the documentation review, confirm or change the billed CPT code(s), diagnosis code(s) and modifiers (if applicable) in order to attain denial resolution. Requires proven knowledge of the specialty specific service line documentation requirements. Must be familiar with the Medicare and Medicaid teaching physician documentation billing rules within 60 days of hire.
5. Serves as a resource to the FERC Team Leads, Compliance Auditors, Medical Collectors and MSRDP Clinical Denials Management Specialist I & II. Requires a billing and coding knowledge level that provides guidance on and resolution to resolve claim denials and rejections.
6. Makes necessary adjustments as required by plan reimbursement.
7. Duties performed may include one or more of the following core functions: (a) Directly interacting with or caring for patients; (b) Directly interacting with or caring for human-subjects research participants; (c) Regularly maintaining, modifying, releasing or similarly affecting patient records (including patient financial records); or (d) Regularly maintaining, modifying, releasing or similarly affecting human-subjects research records.
Performs other duties as assigned.
This position will responsible for the claims follow-up for the Departments of Neurosurgery and Spine and to assist both of the Departments. This specialist can also help as a float to help cover other departments when needed. As of 6/20/17, the Neurosurgery work queue has a volume of 1164 active invoices and for Spine there are 666 active invoices outstanding. This person would be expected to maintain a quality of 98% accuracy while meeting and/or exceeding the production standard of 40 invoices per day. I currently have 1 follow-up staff that help with that department. The volume has and will continue to increase due to addition of the Moncrief Ft Worth location, and several surgical sites with THR, Plaza, and JPS.
UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. In accordance with federal and state law, the University prohibits unlawful discrimination, including harassment, on the basis of: race; color; religion; national origin; gender, including sexual harassment; age; disability; citizenship; and veteran status. In addition, it is UT Southwestern policy to prohibit discrimination on the basis of sexual orientation, gender identity, or gender expression.