experienced insurance claims field investigator

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case administrator (legal support) Jobs in Houston

case administrator (legal support)

claims specialist

director, benefits operations Jobs in Houston

director, benefits operations

experienced insurance claims field investigator Jobs in Houston

lead medical benefits verification specialist

Onco360

<div><div><b>Are you someone looking for professional career growth? </b>Onco360 Pharmacy is looking for a <b>Lead Medical Benefits Verification Specialist</b> for our Pharmacy located in <b>Houston, TX.</b></div>
<div></div><div><b>Work Hours: Monday-Friday 8:30 - 5:00pm CST</b></div>
<div></div><div><b>**Starting salary at $23/hr** </b>We also offer quarterly incentive bonuses.</div>
<div></div><div>We offer a variety of benefits including:</div>
<ul><li>Medical, Dental &amp; Vision insurance</li>
<li>401k with a match</li>
<li>Paid Time Off and Paid Holidays</li>
<li>Tuition Reimbursement</li>
<li>Paid Volunteer Day</li>
<li>Floating Holiday</li>
<li>Referral Incentive</li>
<li>Paid Life, and short &amp; long-term disability insurance</li>
</ul>
<div></div><div><b>Lead Medical Benefits Verification Specialist Summary:</b></div>
<div>The Lead Medical Benefits Verification Specialist is responsible to support the Medical Benefits Verification Specialist roles while performing insurance authorization and verification for all patients scheduled for services. The Lead will investigate, review, and load accurate patient insurance for medical coverage, assign coordination of benefits, and investigate/identify authorization requirements needed to obtain medication coverage. Support the department's Manager with the daily workflow and distribution of workload, answer questions as the assigned subject matter experts, assist with mentoring and training new members of the team and report any system or process issues identified.</div>
<div></div><div><b>Lead Medical Benefits Verification Specialist Major Responsibilities:</b></div>
<div><ul><li>Support staff in verifying Commercial and Government payer eligibility and benefits utilizing electronic resources to load primary, secondary, tertiary, etc. insurances to patient profile. This involves contacting Medicare or other relevant government payers to confirm coverage and benefits for specific services. Verify Commercial insurance plans eligibility and benefits utilizing electronic resources to load primary, secondary, tertiary, etc. insurances to patient profiles. Confirming patient eligibility and benefits with various commercial insurance carriers (i.e. Aetna, Humana, Anthem, Cigna, etc.).</li>
<li>Facilitate process for requesting medical authorizations, Single Case Agreements, Letter of Agreements, and Terms of Agreement for applicable commercial, Medicaid, and Medicare, or facility medication claims.</li>
<li>Investigate payer plans: Research and document benefit plan specifics for various payer plans, including cost-share responsibilities and restrictions. Address intricate benefit verification issues, such as those involving high-cost or specialized treatments, denials, and appeals.</li>
<li>Develop expertise: Maintain in-depth knowledge of insurance policies, coverage terms, and complex billing practices. Identify the appropriate clinical records and</li>
<li>submit the authorization request to the insurance company based on plan requirements for approval.</li>
<li>Handle complex cases: Address intricate benefit verification issues, such as those involving high-cost or specialized treatments, denials, and appeals.</li>
<li>Collaborate across departments: Work closely with clinical staff, billing and coding teams, and administrative teams to resolve insurance issues and ensure seamless patient care. Will be the liaison between the ordering physician and insurance company to ensure all requirements to secure approval are identified and communicated.</li>
<li>Corporate Compliance Agreement, applicable federal and state laws, and applicable professional standards.</li>
<li><div>Lead process improvement: Analyze workflows, identify opportunities for improvement, and implement more efficient procedures to reduce turnaround times and improve accuracy. Assist the Medical Verification Specialists in achieving: &gt;95% accuracy/quality while handling accounts, as measured by account audits &gt;95% quality of expected customer service etiquette, as measured by phone call audits Meet or exceed Lower controls of average productivity amongst the team productivity standards assist the manager of the department with escalated issues, tracking system and process issues.</div>
 </li><li><div>Mentor and train staff: Guide and train junior specialists on proper benefit verification and claim processing procedures.</div>
</li><li><div>Ensure compliance: Adhere to all federal and state regulations, including the Health Insurance Portability and Accountability Act (HIPAA), to maintain patient confidentiality.</div>
</li><li><div>Performs other duties as assigned.</div>
</li></ul></div><div><b>Education/Learning Experience</b></div>
<ul><li>Required: High School Diploma or GED. Previous Experience in Pharmacy, Medical Billing, or Benefits Verification</li>
<li>Desired: Associate degree or equivalent program from a 2-year program or technical school, Certified Pharmacy Technician (PTCB), Specialty pharmacy experience</li>
</ul><div><b>Work Experience</b></div>
<ul><li>Required:
<div>3+ years&rsquo; Medicare and Medical benefit verification experience</div>
</li><li><div>Desired: 5+ years Specialty Pharmacy, Medical Verification, and/or Infusion benefit verification experience</div>
</li></ul><div><b>Skills/Knowledge</b></div>
<ul><li>Required: Medicare and Medical insurance and benefit verification, medical contracts, knowledge/understanding of Medicare, Medicaid, and commercial insurance, coordination of benefits, Understanding Medicare Parts A, B, C, and D, as well as relevant laws and guidelines, NDC medication billing, pharmacy or healthcare-related knowledge, knowledge of pharmacy terminology including sig codes, basic math and analytical skills, Intermediate typing/keyboarding skills.</li>
<li>Desired: Specialty Pharmacy experience, Medicare Billing Experience, Medical Authorization experience</li>
</ul><div><b>Licenses/Certifications
</b></div><ul><li>Required: None</li>
<li>Desired: Registration with Board of Pharmacy as required by state law or Certified Pharmacy Technician (PTCB)</li>
<li><div>Certified Revenue Cycle Representative (CRCR)</div>
<div>Certified Medical Insurance Specialist (CMIS)</div>
</li></ul><div></div><div><b>Behavior Competencies</b></div>
<ul><li>Required: Independent worker, self-motivated<br>
Analytical skills: The ability to interpret complex insurance documents and identify potential gaps in coverage is crucial for handling more difficult cases.<br>
Communication: Excellent verbal and written communication skills are essential for interacting with insurance companies, patients, and other healthcare professionals.<br>
Problem-solving: Senior specialists must possess strong problem-solving skills to efficiently address and resolve insurance-related issues.<br>
Technical proficiency: Expertise in electronic health record (EHR) systems, insurance verification software, and payer portals is necessary.<br>
Leadership abilities: The capacity to mentor junior staff and lead process improvement projects is a key differentiator for a senior role.</li>
</ul>
<div></div><div>Onco360 Pharmacy is a unique oncology pharmacy model created to serve the needs of community, oncology and hematology physicians, patients, payers, and manufacturers.</div>
<div></div><div>A career with us is more than just a job. It's an opportunity to connect and care for our patients, providers, communities and each other. We attract extraordinary people who have a strong desire to live our mission - to better the lives of those battling cancer and rare diseases. Compassion is more important than numbers. We value teamwork, respect, integrity, and passion.</div>
<div></div><div>We succeed when you do, and our company and management team work hard to foster an environment that provides you with opportunities for both professional and personal growth.</div></div>

Lead Medical Benefits Verification Specialist

<div><div><b>Are you someone looking for professional career growth? </b>Onco360 Pharmacy is looking for <b>Pharmacy Benefit Verification Specialists</b> for our Pharmacy located in <b>Houston, TX.</b></div>
<div></div><div><div><b>Work Hours: Monday-Friday shifts available; </b><b>some weekends as needed.</b></div><br>
<div></div>
</div><div></div><div><b>**Starting salary at $24.00/hr and up** </b>We also offer quarterly incentive bonuses.</div><br>
<div></div>
<div></div><div><div>We offer a variety of benefits including:</div>
<div></div><ul><li>Medical, Dental &amp; Vision insurance</li>
<li>401k with a match</li>
<li>Paid Time Off and Paid Holidays</li>
<li>Tuition Reimbursement</li>
<li>Paid Volunteer Day</li>
<li>Floating Holiday</li>
<li>Referral Incentive</li>
<li>Paid Life, and short &amp; long-term disability insurance</li>
</ul>
</div><div></div><div><div><b>Pharmacy </b><b>Benefit Verification</b><b> Summary</b></div>
<div>The Benefit Verification Specialist will investigate, review, and load accurate patient insurances, including medical and pharmacy coverage, assign coordination of benefits, run test claims to obtain a valid insurance response on patient medications, investigate/identify authorization requirements needed to obtain medication coverage, and enroll eligible patients in copay card assistance programs. They will ensure accurate benefit documentation is made for all prescription orders.</div>
<div></div><div><b>Pharmacy </b><b>Benefit Verification</b><b> Specialist Major Responsibilities:</b></div>
<ul><li>Practices first call resolution to help health care providers and patients with their pharmacy needs, answering questions and requests.</li>
<li>Provides thorough, accurate and timely responses to requests from pharmacy operations, providers and/or patients regarding benefit information.</li>
<li>Ensures complete and accurate patient setup in CPR+ system including patient demographic and insurance information.</li>
<li>Performs full benefits verification on patients for pharmacy benefits and/or medical benefit utilizing electronic resources and E1 check to load primary, secondary, tertiary, etc. insurances and medical insurances to patient profile.</li>
<li>Run test claims at each licensed pharmacy site to obtain a valid claim response and determine optimal reimbursement, then document outcome of benefits review in CPR+ system to be used by operations and ensure the order is assigned to the appropriate dispensing pharmacy.</li>
<li>Facilitate process for requesting medical authorizations, LOAs, and TOAs for applicable commercial, Medicaid, and Medicare, or facility medication claims.</li>
<li>Maintain a safe and clean pharmacy by complying with procedures, rules, and regulations and compliance with professional practice and patient confidentiality laws</li>
<li>Contributes to team effort by accomplishing related tasks as needed and other duties as assigned.</li>
<li>Conducts job responsibilities in accordance with the standards set out in the Company&rsquo;s Code of Business Conduct and Ethics, its policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and applicable professional standards.</li>
</ul><div><b>Pharmacy </b><b>Benefit Verification</b><b> Specialist Qualifications:</b></div>
</div><ul><li>Education/Learning Experience
<ul><li>Required: High School Diploma or GED. Previous Experience in Pharmacy, Medical Billing, or Benefits Verification</li>
<li>Desired: Associate degree or equivalent program from a 2 year program or technical school, Certified Pharmacy Technician (PTCB), Specialty pharmacy experience</li>
</ul></li><li>Work Experience
<ul><li>Required: 1+ years pharmacy or benefit verification experience</li>
<li>Desired: 3+ years pharmacy or benefit verification experience</li>
</ul></li><li>Skills/Knowledge:
<ul><li>Required: Pharmacy insurance and benefit verification, PBM and Medical contracts, knowledge/understanding of Medicare, Medicaid, and commercial insurance, pharmacy test claim and NCPDP claim rejection resolution, coordination of benefits, NDC medication billing, pharmacy or healthcare-related knowledge, knowledge of pharmacy terminology including sig codes, and Roman numerals, brand/generic names of medication, basic math and analytical skills, Intermediate typing/keyboarding skills.</li>
</ul></li><li>Behavior Competencies
<ul><li>Required: Independent worker, good interpersonal skills, excellent verbal and written communications skills, ability to work independently, work efficiently to meet deadlines and be flexible, detail-oriented, great time-management skill</li>
</ul></li></ul><div>Onco360 is a Closed door specialty pharmacy that focuses on patients who are currently undergoing cancer treatment. Our patients are important to us, so we always strive to meet and exceed their needs. We are seeking <b>Pharmacy Benefit Verification Specialists</b> who go above and beyond for our patients, and also passionate about helping others.</div></div><div></div>

Pharmacy Benefits Verification Specialist

Premier Medical Resources

<div><div><b>Premier Medical Resources</b> is looking for an <b>Insurance Verification Specialist </b>to join our team!<br>
<br>
<b>**Remote opportunity after 30-90 day in-person training**</b></div>
<div></div><div>The Insurance Verification Specialist is responsible for verifying the patient's insurance coverage, ensuring surgery and procedures are covered by an individual&rsquo;s insurance plan. Creates cost estimates prior to the surgery date and communicates cost to patients. In addition to, entering and verifying accurate data and updating patient benefit information in the Electronic Medical Records (EMR).</div>
<div></div><div><b>ESSENTIAL FUNCTIONS:</b></div>
<ul><li>Assists front office with verification questions or concerns</li>
<li>Resolves any coverage issues and update patient EMR</li>
<li>Enters insurance coverage (co-payments, deductibles, etc.) accurately into patient EMR</li>
<li>Serves as a liaison between the patient, facility, physicians, and other departments to ensure timely and accurate financial clearance of all accounts</li>
<li>Verifies patient insurance coverage and benefits through online portals, phone calls, and other resources</li>
<li>Verifies insurance eligibility along with benefits and ensures all notifications and authorizations are completed by the surgery date</li>
<li>Identifies patient accounts based on self-pay, PPO, HMO, personal injury, workmen&rsquo;s compensation or other managed care organizations</li>
<li>Collects relevant data for eligibility and benefit verification including all ICD-10 and billable CPT codes per orders</li>
<li>Communicates with internal and external individuals to obtain information, resolve benefit issues, and ensure accurate benefit information is obtained</li>
<li>Responds to inquiries regarding patient accounts with appropriate and accurate information in a professional manner</li>
<li>Ensures accounts are financially secured by reviewing and documenting benefits, patient responsibilities, authorization requirements, and other relevant information</li>
<li>Creates financial arrangements, alongside management, when a patient is unable to complete payment</li>
<li>Responds promptly to requests and keeps open channels of communication with physician, patient, and service areas regarding financial clearance status and resolution</li>
<li>Collaborates with billing and coding departments to ensure correct processing of claims</li>
<li>Calculates co-pay, and estimated co-insurance due from patients per the individual payer contract per the individual payer contract and plan as applicable</li>
<li>Completes high-quality work while adhering to productivity standards</li>
<li>Performs miscellaneous job-related duties as assigned</li>
</ul>
<div></div><div><b>KNOWLEDGE, SKILLS, AND ABILITIES:</b></div>
<ul><li>Demonstrates ability to use basic computer functions, technology and Microsoft office (excel, word)</li>
<li>Broad knowledge of the content, intent, and application of HIPAA, federal and state regulations</li>
<li>Ability to work independently with little or no supervision as well as function within a team</li>
<li>Knowledge with in and out of network insurances, insurance verification, patient responsibility, and process for prior authorization</li>
<li>Good communication skills (verbal / written) providing a great patient experience</li>
<li>Ability to work effectively in a fact paced environment</li>
<li>Strong knowledge of managed care, medical terminology, CPT Coding and ICD10</li>
<li>Demonstrates use of appropriate modifiers, HIPAA regulations, and insurance verification procedures</li>
<li>Knowledge of payor guidelines including reading, understanding and interpreting medical records and payor requirements etc.</li>
<li>Ability to think critically, assess problems and provide problem resolutions</li>
<li>Demonstrates attention to detail, accountability, people skills, problem solving and decision-making skills</li>
</ul>
<div></div><div><b>EDUCATION AND EXPERIENCE:</b></div>
<ul><li>High School Diploma or GED</li>
<li>One (1) year of hospital revenue cycle experience</li>
<li>One (1) year of general customer service experience</li>
</ul>
<div></div><div><div><b>BENEFITS:</b></div>
<ul><li>3 Medical Plans</li>
<li>2 Dental Plans</li>
<li>2 Vision Plans</li>
<li>Employee Assistant Program</li>
<li>Short- and Long-Term Disability Insurance</li>
<li>Accidental Death &amp; Dismemberment Plan</li>
<li>401(k) with a 2-year vesting</li>
<li>PTO + Holidays</li>
</ul>
</div><div></div><div><div>Please visit our website for more information:</div>
<div>www.pmr-healthcare.com</div>
<div><br>
<b>Premier Medical Resources</b> is a healthcare management company headquartered in Northwest Houston, Texas. At Premier Medical Resources, our goal is to leverage and combine the expertise and skillset of our employees to drive quality in all we do. Our goal is to create career pathways for our employees just starting their professional career, and to those who seek to bring their expertise and leadership as we strive to combine best practices and industry excellence. Come join our team at Premier Medical Resources where passion and career meet.<br>
<br>
<b><i>Compensation to be determined by the education, experience, knowledge, skills, and abilities of the applicant, internal equity, and alignment with market data. Employment for this position is contingent upon the successful completion of a background check and drug screening.</i></b></div></div></div>

Insurance Verification Specialist (Clinic)

Blue Fish Pediatrics

<p>We are currently looking for a full-time (35-40 hrs/week) Insurance Verification Specialist. This person is responsible for verifying and recording up-to-date health insurance benefits for patients in our EMR software. This employee will be based at our Cypress office, which is located at 9530 Huffmeister Rd.</p><p>An ideal candidate for this position will possess the following qualities:</p><p>- Quick-learner</p><p>- Detail-oriented</p><p>- Accurate</p><p>- Types 50+ WPM</p><p>Previous experience in a similar role at a medical practice is preferred but not required. Working knowledge of eClinical Works is a plus</p><p>Please do not call our office directly as only those candidates who apply via Indeed will be considered.</p><p>Job Type: Full-time</p><p>Pay: $14.00 - $17.00 per hour</p><p>Benefits:</p><ul><li>401(k) matching</li><li>Dental insurance</li><li>Health insurance</li><li>Paid time off</li><li>Vision insurance</li></ul><p>Education:</p><ul><li>High school or equivalent (Required)</li></ul><p>Work Location: In person</p>

Insurance Verification Specialist

<div><div>We are seeking a Pharmacy Adjudication Specialist at our Specialty pharmacy in<b> Houston, TX. </b>This will be a Full-Time position.<b> This position must be located within driving distance to our pharmacy, with a hybrid work style.</b></div>
<div></div><div>Onco360 Pharmacy is a unique oncology pharmacy model created to serve the needs of community, oncology and hematology physicians, patients, payers, and manufacturers.</div>
<div></div><div><b>Starting salary from $21.00 an hour and up</b></div>
<div></div><div>We offer a variety of benefits including:</div>
<ul><li>Medical; Dental; Vision</li>
<li>401k with a match</li>
<li>Paid Time Off and Paid Holidays</li>
<li>Tuition Reimbursement</li>
<li>Company paid benefits &ndash; life; and short and long-term disability</li>
</ul><div><b>Pharmacy Adjudication </b><b>Specialist Major Responsibilities:</b></div>
<div>The Pharmacy Adjudication Specialist will adjudicate pharmacy claims, review claim responses for accuracy. ensure prescription claims are adjudicated correctly according to the coordination of benefits, resolve any third-party rejections, obtain overrides if appropriate, and be responsible for patient outreach notification regarding any delay in medication delivery due to insurance claim rejections</div>
<div></div><div>Pharmacy Adjudication Specialists at Onco360...</div>
<ul><li>Practices first call resolution to help health care providers and patients with their pharmacy needs, answering questions and requests.</li>
<li>Provides thorough, accurate and timely responses to requests from pharmacy operations, providers and/or patients regarding active claims information..</li>
<li>Ensures complete and accurate patient setup in CPR+ system including patient demographic and insurance information.</li>
<li>Adjudicates pharmacy claims for prescriptions in active workflow for primary, secondary, and tertiary pharmacy plans and reviews claim responses for accuracy before accepting the claim.</li>
<li>Contacts insurance companies to resolve third-party rejections and ensures pharmacy claim rejections are resolved to allow for timely shipping of medications. Performs outreach calls to patients or providers to reschedule their medication deliveries if claim resolution cannot be completed by ship date and causes shipment delays</li>
<li>Ensures copay cards are only applied to claims for eligible patients based on set criteria such as insurance type (Government beneficiaries not eligible)</li>
<li>Manages all funding related adjudications and works as a liaison to Onco360 Advocate team.</li>
<li>Assists pharmacy team with all management of electronically adjudicated claims to ensure all prescription delivery assessments are reconciled and copay payments are charged prior to shipment.</li>
<li>Serves as customer service liaison to patients regarding financial responsibility prior to shipments, contacts patients to communicate any copay discrepancy between quoted amount and claim and collects payment if applicable.</li>
<li>Document and submit requests for Patient Refunds when appropriate.</li>
</ul><div>Pharmacy Adjudication Specialist Qualifications and Responsibilities...</div>
<div><ul><li>Education/Learning Experience
<ul><li>Required: High School Diploma or GED. Previous Experience in Pharmacy, Medical Billing, or Benefits Verification, Pharmacy Claims Adjudication</li>
<li>Desired: Associate degree or equivalent program from a 2 year program or technical school, Certified Pharmacy Technician, Specialty pharmacy experience</li>
</ul></li></ul><ul><li>Work Experience
<ul><li>Required: 1+ years experience in Pharmacy/Healthcare Setting or pharmacy claims experience</li>
<li>Desired: 3+ years experience in Pharmacy/Healthcare Setting or pharmacy claims experience</li>
</ul></li></ul><ul><li>Skills/Knowledge
<ul><li>Required: Pharmacy/NDC medication billing, Pharmacy claims resolution, PBM and Medical contracts, knowledge/understanding of Medicare, Medicaid, and commercial insurance, NCPDP claim rejection resolution, coordination of benefits, pharmacy or healthcare-related knowledge, knowledge of pharmacy terminology including sig codes, and Roman numerals, brand/generic names of medication, basic math and analytical skills, Intermediate typing/keyboarding skills</li>
<li>Desired: Knowledge of Foundation Funding, Specialty pharmacy experience</li>
</ul></li></ul><ul><li>Licenses/Certifications
<ul><li>Required: Registration with Board of Pharmacy as required by state law</li>
<li>Desired: Certified Pharmacy Technician (PTCB)</li>
</ul></li></ul><ul><li>Behavior Competencies
<ul><li>Required: Independent worker, good interpersonal skills, excellent verbal and written communications skills, ability to work independently, work efficiently to meet deadlines and be flexible, detail-oriented, great time-management skills</li></ul></li></ul></div></div>

Pharmacy Adjudication Specialist

Houston Methodist

<div>At Houston Methodist, the Sr Coding Specialist position is responsible for applying correct coding conventions to patient charge encounters in a clinical environment. This position abstracts diagnosis and procedural services from the physician record and reviews and corrects charge review and claim edit related coding errors in the electronic health record. In addition, the Sr Coding Specialist position is responsible for reviewing, correcting and appealing coding related claim denials and mentoring and cross training Coding Specialists.
<div><b>FLSA STATUS</b><br>
Non-exempt<br>
<br>
<b>QUALIFICATIONS</b><br>
<br>
<b>EDUCATION</b><ul><li>
High School diploma or equivalent education (examples include: GED, verification of homeschool equivalency, partial or full completion of post-secondary education, etc.)
</li></ul><br>
<b>EXPERIENCE</b><ul><li>
Five years of professional coding experience
</li></ul><br>
<b>LICENSES AND CERTIFICATIONS</b><br>
<b>Required</b><ul><li>
Must have one of the following: &bull;CCS - Certified Coding Specialist (AHIMA) &bull;CPC &ndash; Certified Professional Coder (AAPC)
</li></ul><br>
<b>SKILLS AND ABILITIES</b><ul><li>
Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing skills, competency assessments, and performance evaluations
</li><li>Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
</li><li>Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
</li><li>Knowledge of ICD-9, ICD-10, and CPT codes
</li><li>Working knowledge of medical terminology, anatomy, and physiology
</li><li>Proficiency with Microsoft Office applications such as Word and Excel
</li><li>Must be a self-motivated individual with the ability to think critically and work independently
</li><li>Must have the ability to multi-task in a fast paced rapidly changing healthcare environment
</li><li>Demonstrates a high level of professionalism, customer service, and interpersonal skills and operates under strict confidentiality guidelines
</li>Strong training, leadership, and mentoring skills<br>
<li>
</li></ul><br>
<br>
<b>ESSENTIAL FUNCTIONS</b><br>
<br>
<b>PEOPLE ESSENTIAL FUNCTIONS</b><ul><li>
Communicates regularly with physicians and Physician Organization Central Business Office (PO CBO) staff on clarification to accurately code diagnosis and procedures.
</li><li>Collaborates with management on coding and diagnosis issues to reduce claims denials by providing verbal and written communication.
</li><li>Assists with knowledge sharing, training Coding Specialists, and department cross training; provides support to other team members as advised by the manager and/or supervisor.
</li></ul><br>
<b>SERVICE ESSENTIAL FUNCTIONS</b><ul><li>
Responds to or clarifies internal requests from all business partners for medical coding information in a timely manner.
</li><li>Participates in coding round tables and in-services for continuing education.
</li><li>Cross trains and provides back up coverage of team members to ensure continuous coding and charge capture activities for PO departments.
</li></ul><br>
<b>QUALITY/SAFETY ESSENTIAL FUNCTIONS</b><ul><li>
Codes and abstracts medical records for reimbursement purposes from patient charts, physician documentation, and medical diagnostic and/or interventional reports using current coding conventions and guidelines and tools such as 3M encoder.
</li><li>Reviews individual medical records to verify and substantiate diagnosis and procedures for charge review, claim edit(s) and/or denied claims and submits clinical appeal or corrected claim.
</li><li>Assists with the creation and review of department specific coding workflows and expectations.
</li></ul><br>
<b>FINANCE ESSENTIAL FUNCTIONS</b><ul><li>
Matches charge documents to charge review &amp; claim edit sessions, billing sheets, operative reports, and medical records to ensure correct codes are applied and billable services are captured.
</li><li>Works charge review and claim edit sessions within two business days of posting to the assigned work queues.
</li><li>Investigates and appeals unpaid, denied and partially paid claims by third party payors.
</li></ul><br>
<b>GROWTH/INNOVATION ESSENTIAL FUNCTIONS</b><ul><li>
Pursues ongoing professional growth and development and participation in team meetings.
</li><li>Provides on-going coding and documentation education to physicians and clinical staff.
</li>Attends, in person, quarterly coding and revenue integrity team meetings.<br>
<li>
</li></ul><br>
<br>
<b>SUPPLEMENTAL REQUIREMENTS</b><br>
<ul><b>
WORK ATTIRE</b><li><ul><li>
Uniform: No
</li><li>Scrubs: No
</li><li>Business professional: Yes
</li><li>Other (department approved): No
</li></ul></li><br>
<b>ON-CALL*</b><br>
<li><ul><li><i>Note that employees may be required to be on-call during emergencies (ie. Disaster, Severe Weather Events, etc) regardless of selection below.</i></li></ul></li><li><ul><li>
On Call* No
</li></ul></li><br>
<b>TRAVEL**</b><br>
<i>**Travel specifications may vary by department**</i><li><ul><li>
May require travel within the Houston Metropolitan area Yes
</li><li>May require travel outside Houston Metropolitan area No
</li></ul></li></ul></div><b>QUALIFICATIONS</b><br>
<br>
<b>EDUCATION</b><ul><li>
High School diploma or equivalent education (examples include: GED, verification of homeschool equivalency, partial or full completion of post-secondary education, etc.)
</li></ul><br>
<b>EXPERIENCE</b><ul><li>
Five years of professional coding experience
</li></ul><br>
<b>LICENSES AND CERTIFICATIONS</b><br>
<b>Required</b>
Must have one of the following: &bull; CCS - Certified Coding Specialist (AHIMA) &bull; CPC &ndash; Certified Professional Coder (AAPC)<br>
<ul><li>
</li></ul><br>
<p><b>Company Profile:</b></p><p>
Houston Methodist Specialty Physician Group is an integral part of Houston Methodist&rsquo;s overall strategy to become one of the nation&rsquo;s leading academic medical centers. Established as a nonprofit corporation certified by the Texas State Board of Medical Examiners, the Specialty Physician Group enables physicians to maintain autonomy with respect to clinical practice while growing their practice within an academic environment.</p><p>
Houston Methodist is an Equal Opportunity Employer.</p></div>

Senior Coding Specialist - Remote - Must Reside in TX

Senior Psych Care

<div><p><b>Senior PsychCare</b> has an immediate opportunity for a<b> Revenue Cycle Specialist II </b>to support our Billing Team in Houston.</p><p><b>
ABOUT US:</b></p><p>
Senior Psych Care provides fully integrative behavioral health services to the long-term care patient, at their facility. Services include individual, family, and group therapies, along with diagnostic evaluation and collaborative intervention between the therapy team and the psychiatric team.</p><p><b>
Job Description</b></p><p><b>
Revenue Cycle Specialist II</b> is responsible for processing follow-up actions on claims denied for eligibility-related reasons and responding to health plan correspondence. In this role, you would identify billing issues affecting the provider&rsquo;s claims and take necessary action to ensure timely and appropriate claim filing. In addition, perform follow-up activities and identifies reimbursement issues affecting these claims. The Revenue Cycle Specialist also takes necessary actions to insure accurate reimbursement and account resolution.</p><p><b>
Responsibilities :</b></p><ul><li>
Responsible for managing and maintaining a workload of approximately seventy (70) accounts or higher per day to ensure claim(s) resolution.</li><li>
Leverage knowledge of Medicare, state Medicaid, and local coverage determinations (LCD&rsquo;s) for claim resolution.</li><li>
Review and attach appropriate documentation to resolve denied claims and submit appeals.</li><li>
Call payers to determine the true reason for denial and inquire on what corrections need to be made.</li><li>
Follow-up with payers to ensure timely resolution of all outstanding claims, via phone, emails, fax or payer portals.</li><li>
Review underpayments and overpayments, work with management to prepare spreadsheet and summarize findings; escalate as appropriate.</li><li>
Prepare and submit denied claims targeted project files to payers, track reprocessing of project files.</li><li>
Identify problematic claim trends and contract violations and report findings to the Manager and Director.</li><li>
Contact insurers regarding recoupment payments, double debits, overpaid accounts, and missing checks; initiate dispute process as needed.</li><li>
Update insurance information in the system as necessary, initiate and support primary, secondary and tertiary billing.</li><li>
Perform other duties assigned by Revenue Cycle Manger.</li></ul><p><b><i>
This is a full-time, in-person opportunity. Our work week is from Monday-Friday 8am-5pm (NO WEEKENDS Required).</i></b></p><p><b>
Qualifications-Required Experience: 3+ years of recent Healthcare experience, specifically in a claims, Denials, billing, EOB and insurance verification.</b></p><ul><li><b>
Minimum 1+ years&rsquo; experience in Government Payor follow- up (Required)</b></li><li><b>
Ability to work independently and prioritize monthly workflow (Required)</b></li><li><b>
Knowledge of Medical Terminology, CPT Codes, HCPCS, Revenue Codes, Modifiers and Diagnosis Codes (Required)</b></li><li><b>
Payer portal and clearinghouse experience (Required)</b></li><li><b>
Ability to work independently and prioritize monthly workflow (Required)</b></li><li><b>
Mental Health experience (Preferred)</b></li></ul><p><b>
What we offer:</b></p><ul><li>
Paid Time Off and Paid Holidays</li><li>
Comprehensive benefits packages including Medical, Dental, Vision, 401k, Long Term and Short-Term Disability, Life Insurance</li><li>
Healthcare coverage available 1st day of the month following full-time employment.</li></ul><p><b><i><br>
All interested candidates are encouraged to apply. Apply today and START NEXT WEEK!!!</i></b></p></div>

Revenue Cycle Specialist II – Appeals and Denials

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