Claims Analyst/ Clinical coding/RCM
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Skilled and 14 years experienced Revenue Cycle Specialist has strong knowledge of medical billing and coding practices. Knowledgeable about insurance companies, prior authorization protocols, submission, and reimbursements. Has a professional Certificate in Medical Coding as a Certified Coding Specialist from American Health Information Management.
Ensure effective claims submission and re-submission. (All areas pertaining to a hospital -OP, Daycare, IP, ER)
Ensure effective use of 3M. IR-DRG identification and H.I.S module to support reimbursement efficiency in line with physician documentation needs for an insurance claim.
Review rejection trends based on denial codes due to medical necessity & other rejection areas; suggest corrective improvements and education where required.
Work with physicians in supporting education needs to reduce insurance rejections.
Identify issues faced from registration and billing, which affects the overall claims and suggest improvements required.
Resubmitting claims with proper justification and required documents as per denial code within time limits.
Initiating reconciliation for the closure of financial year with clinician justification and required documents.
Assigning appropriate ICD-10/CPT codes as per coding/DOH guidelines.
Requesting approval for the services which need prior authorization based on insurance guidelines with all required documents and resubmitting the rejected approvals with proper justification and required documents within time limit.
Follow up with payers for rejected claims and escalating to clinician for justification of the services.
Identify physician education programs with the Revenue Cycle Manager for corrective improvements to reduce medical necessity denials and improve DRG efficiency.
Work with HIS, IT and operational teams to allow smooth flow of claims processes.
Assess opportunities to improve internal workflows; ensure best methods and tools are utilized.
