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Hospital Review Analyst
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| Prepayment Review |
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| Location: 441 9th Avenue |
| HRA PR |
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| Essential Duties: |
Assists in reviewing hospital claims not complying with American Hospital Association, American Medical Association, CMS and industry standard pre-defined coding guidelines related to ICD-9-CM, CPT and HCPCS coding and coverage.
- Reviews DRG and APC claims, performing DRG/APC analysis, assists in the preparation of Prepayment guidelines, which are consistent with industry standard coding guidelines and corporate objectives.
- Analyzes health claim history reports to identify provider coding and billing patterns and determines the appropriateness of the ICD-9-CM, CPT, HCPCS and Revenue Codes data billed to describe hospital medical and ancillary services performed in conjunction with subscribers' illnesses.
- Prepares written correspondences to hospitals and ensures timely and efficient handling of written and telephone providers inquiries related to claims coding guidelines and reimbursement.
- Performs single-patient negotiations on hospital claims submitted by non-participating facilities.
- Assists area management in medical claims processing studies, to determine claims editing trends, documents root-cause and recommends changes in methods, procedures and policies to improve quality, and consistency with industry standard coding guidelines and identifies hospital claims system coding issues and assists in the formulation of system efficiency recommendations to ensure exceptions reduction through the implementation of automated coding rules.
- Assists manager in the analysis of reimbursement policies and procedures, and ensures compliance and efficient and effective administration of provider contracts, recommending changes when necessary.
- Assists area manager in overseeing the proper handling of extra-contractual claims, Special Investigations claims and ensuring compliance with existing claims processing and review guidelines.
Knowledge Skills & Abilities:
- Strong industry and position knowledge
- Skilled negotiator
- Commitment
- Reliability
- Attention to detail
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| Qualifications: |
- 5 years previous DRG coding experience in hospital inpatient (ICD-9-CM) and ambulatory care (ICD-9-CM and CPT) medical record coding.
- 3-5 years experience in healthcare pay or operational environment with specific concentration in claims processing/editing software.
- Knowledge of CPT-4 and HCPCS coding and medical terminology.
- Strong knowledge of hospital/medical contracts, procedures and systems.
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