Job Summary: Clinical Denial Representative is responsible to review patients medical claim when resolving edits for compliance (prior billing) and issues on rejections(rejected by the payor) in the physician side. Clinical Denial Representative must understand and comply with federal and state coding and billing regulation. The Clinical Denial Representative must ensure the confidentiality and privacy of information.
Essential Functions: 1. Prepare and process accounts timely and accurately based on client requirement.
2. Review daily account/edit reports from work queues and/or in external billing software and makes necessary corrections or resolve edits to allow electronic submission.
a. Resolving edits prior billing (Compliance)
b. Resolving rejections from the payor (Rejection)
3. Reviews and make appropriate actions such as but not limited to: a. Medical Necessity edits,
a. Medical Necessity edits,
b. Local Coverage Determination (LCD) and National Coverage Determination (NCD) edits
c. National Correct Coding Initiative (NCCI) edits
d. Modifier edits
e. Payer specific edits
f. Medically Unlikely Edits (MUE)
g. Procedure to Procedure (PTP) edits
h. Diagnosis issue
4. Enter appropriate account notes into the billing system to clarify actions taken to reconcile claims.
5. Maintains confidentiality of patient records at all times Observes HIPAA compliance.
6. Perform as a team player.
7. Use logic, critical thinking and reasoning to identify the strengths and weaknesses of alternative solutions to problems.
8. Understand the effects of new information for both current and future problem-solving and decision-making.
9. High attention to detail
10. Attendance in accordance with company HR and department policies
11. Other tasks/functions that may be assigned by the company as per business requirement; these may change from time to time to reflect the changing requirement of your position and our business
Education/Experience Requirements: 1. Bachelor of Science in Nursing graduate or Medical Allied Health Course
2. Preferably with work experience in
a. Revenue Cycle (medical coding) experience.
b. Knowledge of medical and billing terminologies, ICD-10 diagnosis coding guidelines, CPT procedures.
c. Clinical or Hospital setting Certification/licensure:
Certification is required AAPC Coding Certification: CPC, COC, CIC
AHIMA Coding Certification: CCA, CCS-P, CCS
Work from Home Set-up
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