Appeals Coordinator - Phoenix, AZ
- - 3625F - Admin-FIN-EMS-Mgmt
- Phoenix, AZ, USA
- Full Time 5&2
- Provides initial review of all second level, clinical type denials and technical denials
- Researchers clinical records, appropriate insurance regulations and history of claim to determine next step
- Utilizes appropriate resources to gather supporting documentation: 1) State EMS protocols 2) Hospital medical records 3) State or Federal Statutes or 4) Patient/Physician letters
- Interfaces with clinical management to assist in medical necessity type denials
- Assists in gathering all documents, reviewing past submissions and scheduling appropriate parties for ALJ proceedings
- Ensures proper documentation of all denials into billing systems to include tracking outcome for reporting to appropriate parties
- Manages assigned queues and categories of appeals to ensure timely submissions
- Monitors volume of appeals in order to engage additional resources when needed
- Negotiates with payers for pay-in-full arrangements during escalation process
- Assists management with CQI of first level staff appeals to ensure appropriateness and quality of submissions
- Forms professional relationships with payer appeals and utilization departments
- Solicit hospital records, physician letters, and patient submissions to compile documentation for appeal support
- Assists in the resolution of high level payment issues that presents financial risk'including but not limited to: self-pay judgments, benefit limitations, timely filing, and prior-authorization issues
- Provides communications regarding receipt of new payer requirements, regulations and denial trends
- Researches payer statutes, regulations, regional requirements to support appeal submissions
- Demonstrates ability to draft professional letter by incorporating supporting documents, policies and statutes
- Other duties and responsibilities as assigned
- Responsible for supporting company Safety Management System activities
- Complying with company HS&E policies and procedures
- Understand and provide visible support of Destination Zero
- Requires 8+ years' experience in medical billing, billing in emergency medical services and collections preferred
- College degree preferred but will substitute applicable work experience
- Medicare, Managed Care, Workers' Comp. knowledge and experience in processing
- Extensive medical appeals background
- Must demonstrate the ability to draft a professional and effective letters
- Expertise in billing software and Internet-based research required
- Must have solid knowledge of patient account systems, revenue management processes, work flow systems and the ability to troubleshoot and suggest improvements
- Ability to work independently and organize/prioritize work to meet departmental goals
- Strong interpersonal skills to effectively interact with customers, payers and with PFS employees
- Must have demonstrated experience in researching statutes and understanding regulatory documents
- Must be able to pass pre-placement drug screening and background screen
- This position is designated Safety Sensitive for purposes of the Arizona Medical Marijuana Act.
- Regular pay scale applies
- Safe. We are absolute in our belief in the tenets of Destination Zero and that Zero is not only achievable, but the only acceptable outcome.
- Efficient. We are focused on outcomes that are smart and responsible by making the best use of our resources to maximize overall productivity and achieve sustainable profitability as a high performing organization.
- Quality. We are committed to ensuring excellent organizational performance which produces sustainable and reliable outcomes.
- Service. We are dedicated to the service of our customers, our communities and each other.
- Drive & Energy - Effective performers have a high level of energy and the motivation to sustain it over time. They are ambitious and passionate about their role in the organization. They have the stamina and endurance to handle the substantial workload present in today's organization. They are motivated to maintain a fast pace and continue to produce even in exhausting circumstances.
- Functional/Technical Expertise - Effective performers are knowledgeable and skilled in a functional specialty (e.g., finance, marketing, operations, information technologies, human resources, etc.). They add organizational value through unique expertise in a functional specialty area. They remain current in their area of expertise and serve as a resource in that area for the organization.
- High Standards - Effective performers establish and model standards that guarantee exceptional quality and necessary attention to detail. They continually seek to improve processes and products, and they hold staff accountable for quality. They find best practices, share them, and then improve upon them.
- Initiative - Effective performers are proactive and take action without being prompted. They don't wait to be told what to do or when to do it. They see a need, take responsibility and act on it. They make things happen.
- Integrity - Effective performers think and act ethically and honestly. They apply ethical standards of behavior to daily work activities. They take responsibility for their actions and foster a work environment where integrity is rewarded.
- Conflict Management - Effective performers recognize that conflict can be a valuable part of the decision-making process. They are comfortable with healthy conflict and they support and manage differences of opinion. They thwart destructive competition or friction and use consensus to debate and resolve issues.
- Mission Focus - Effective performers understand and support the organization's mission – its core purpose for being. They believe in the mission, value it, and are committed to it. They communicate it to staff, stand behind it, and interpret its applications for others. They frequently refer to the mission and incorporate it into daily activities.
- Positive Impact- Effective performers make positive impressions on those around them. They are personable, self-confident, and generally likeable. They are optimistic and enthusiastic about what they do, and their excitement is contagious. They energize those around them.
- Problem Solving & Decision Making- Effective performers are able to identify problems, solve them, act decisively, and show good judgment. They isolate cause from symptoms, and compile information and alternatives to illuminate problems or issues. They involve others as appropriate and gather information from a variety of sources. They find a balance between studying the problem and solving it. They readily commit to action and make decisions that reflect sound judgment.
- Team Player - Effective performers are team oriented. They identify with the larger organizational team and their role within it. They share resources, respond to requests from other parts of the organization, and support larger legitimate organizational agendas as more important than local or personal goals.
Hiring Manager: Martha Greer
PHI Air Medical https://phiairmedical.hirecentric.com