Healthcare Claims Appeals Auditor Representative - Wausau, ... - UnitedHealth Group - Wausau, WI

Healthcare Claims Appeals Auditor Representative - Wausau, WI more... ?
October 19, 2011 (last updated 3 hours 17 min ago)

Position Description:Positions in this function are responsible for providing expertise or general support to teams in reviewing, researching, investigating, negotiating and resolving all types of appeals. Position Responsibilities:

* Maintains a good understanding and interpretation of plan language of all plan benefits for assigned customer accounts including all product lines.

* Reviews appeals based on priority basis by completion of expected turnaround time and in compliance with DOL regulations to avoid penalties/fines.

* Completes a backend Quality Review by checking specific Plan language, verifying benefit information and reviewing bill copy for accuracy of Patient, Date of Service, dollar amount, CPT codes, and Provider name.

* Reviews all documentation in specific system applications.

* Recognizes when to refer claims to our compliance and/or legal department that have potential to become a legal/financial risk.

* Recognizes concerns involving medical judgment issues and refers to Registered RN and determines what additional medical documentation is necessary and requests such information prior to referral. Makes the appeal determination and generates a resolution letter and finalizes all documents related to an appeal review by closing out the database entries.

* Makes sure the letter has all the correct information to be DOL and HIPAA compliant by including specific wording to Appeal Levels, number of days to file, and where to file as outlined in each of the specific Plans.

* Maintains operations by following policies and procedures according to DOL and HIPAA regulations. Maintains customer confidence and protects operations by keeping information confidential.

* Provides the very best customer service to claimants, customers, providers of service and internal personnel concerning appeal reviews.

* Communicates with appropriate parties regarding appeals issues, implications and decisions.

* Analyzes and identifies trends for appeals and may research and resolve written Department of Insurance complaints and complex or multi-issue provider complaints submitted by consumers and physicians/providers.

* Production and quality standards must be met on a daily and monthly basis

UnitedHealthcare Employer & Individual is part of the family of companies that make UnitedHealth Group one of the leaders across most major segments of the US health care system.

When you work with UnitedHealthcare Employer & Individual, what you do matters. It*s that simple...and it*s that challenging.

In providing consumer-oriented health benefit plans to millions of people, our goal is to create higher quality care, lower costs and greater access to health care. Join us and you will be empowered to achieve new levels of excellence and make a profound and personal impact as you contribute to new innovations in a vital and complex system.

Regardless of your role at UnitedHealthcare Employer & Individual, the support you feel all around you will enable you to do what you do with energy, integrity, and confidence. So take the first step in what is sure to be a fast paced and highly diversified career.

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Surgical Bill Provider Appeals Analyst - Travelers Import - Tampa, FL

Surgical Bill Provider Appeals Analyst more... ?
October 29, 2011 (last updated 21 hours 25 min ago)

Solid reputation, passionate people and endless opportunities. That's Travelers. Our superior financial strength and consistent record of strong operating returns mean security for our customers - and opportunities for our employees. You will find Travelers to be full of energy and a workplace in which you truly can make a difference.

SUMMARY: Under general supervision this position is responsible for examining and evaluating previously paid complex surgical bills based on additional information submitted by medical providers to determine and generate correct payment. Responding to escalated calls from medical providers regarding payment decisions for surgical services. Providing Medical Provider Appeals Analysts with expert technical support for most complex medical issues. Responsible for keeping abreast of rules, regulations and contracts that are continuously changing PRIMARY DUTIES: Perform a detailed review of previously submitted complex surgical services bills along with accompanying reports/information for accuracy and to determine appropriateness. Using multiple screens on the Medical Bill Re-pricing System, read and interpret scanned complex surgical reports to determine that procedures on bill were actually performed and coded to reflect the services that were actually provided. Compare bill and rates with appropriate fee schedule rules, clinical edits, and Medicare, National Correct Coding Initiative (NCCI), internal Travelers protocols and PPO contracts to determine whether additional payment is due or if recovery of overpayment is necessary. Compile surgery, anesthesia, and co-surgeon, assistant, and hospital bills to determine if there is overlap or duplication of any services and that appropriate Diagnosis Related Grouping (DRG), coding, trauma, and implantable surgical devices are used. Identify each instrumentation item used and re-price using invoices or data base. Apply payment policies to medical supplies and drugs/ medicine. Make accurate payments to medical providers based on the results and analysis of each medical bill. If original decision will be upheld, develop a formal response with supporting documentation. Commence recovery measures, when overpayment has occurred. Serve as the liaison between the provider and company including department leadership, Travelers Claim Product team and third party vendors Regularly and independently identify and bring to managements attention any unusual/new medical or surgical procedures or billing anomalies identified during the review. In addition to day-to-day responsibilities, participates on high volume special projects in support of the New Product team. Deliver superior customer service to Travelers Claim professionals and those medical providers with escalated issues. Answer questions and analyze and resolve problems. Provide expert medical advice to Medical Provider Appeals Analysts. Assist management by providing mentorship and training to raise the overall level of medical proficiency. EDUCATION/COURSE OF STUDY: College degree and /or equivalent work experience preferred.

WORK EXPERIENCE: Registered Nurse or Licensed Practical Nurse with Surgical experience Orthopedic surgery experience, a plus. 10+ years of clinical experience CERTIFICATES/DEGREES: Certified Coder preferred or commensurate experience with the following resource materials: Current Procedural Terminology (CPT) International Classification of Diseases-9 Revision (ICD-9) Healthcare Common Procedural Coding System- 9th Revision (HCPCS) codes Itemized hospital bills, hospital records. Certified California Medical Bill Reviewer a plus. Able to handle very complex and unusual coding and procedures Certified California Medical Bill Reviewer, a plus.

COMMUNICATION SKILLS: Solid customer service telephone skills. Strong interpersonal communication skills. Strong verbal and written communication skills, including effective sentence construction, grammar, spelling, and punctuation.

COMPUTER SKILLS: Basic computer skills: ability to toggle between screens to find data that is needed to process medical bills. Proficiency in Microsoft Office products (e.g. Excel, Power Point, Word, Outlook) OTHER: Must have excellent working knowledge of human anatomy & medical terminology. Working knowledge of Workers Compensation processes and procedures including fee schedule and payment rules preferred.

Solid math skills: must be able to quickly and accurately add, subtract, multiply and divide with the assistance of a calculator. Proven ability and interest in staying abreast of new and emerging surgical trends and literature. Strong attention to detail and ability to independently reads and comprehend completely the details of a surgical operative report and notes and assess them against all appropriate rules and protocols. Must have proficient knowledge of medications and dosages. Able to identify medication as to whether it is a capsule, pill, inject able, intrathecal, or topical. Proven ability to effectively coach and mentor co-workers with less medical knowledge. Strong comprehension and analytical skills Ability to produce high quality results in a high production environment Superior Organizational Skills and Attention to Detail Commitment to Task Continuous Learning Decision Making and Problem Solving skills. Decisiveness Sense of urgency Flexibility Travelers is an equal opportunity employer. We actively promote a drug-free workplace.

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Unit Manager, Medical/Surgical Bill Provider Appeals - Travelers Import - Tampa, FL

Unit Manager, Medical/Surgical Bill Provider Appeals more... ?
October 29, 2011 (last updated 21 hours 24 min ago)

Solid reputation, passionate people and endless opportunities. That's Travelers. Our superior financial strength and consistent record of strong operating returns mean security for our customers - and opportunities for our employees. You will find Travelers to be full of energy and a workplace in which you truly can make a difference.

SUMMARY: This position is responsible for providing direction and leadership to a team comprised of medical and surgical provider appeal analysts. Ensuring accuracy and timeliness of reviewing and analyzing appeals. Selecting and training staff. Initiating all human resources actions (performance management, performance assessments and ratings, salary & rewards and recognition administration, etc.) PRIMARY DUTIES: Establish, monitor and deliver individual team goals based on overall office Service Level Agreement (SLA) Coordinate work activities to ensure appropriate deployment of resources to maximize productivity and ensure highest level of service Motivate team members by providing training, honest constructive performance feedback and counseling. Ensure proper bill review handling techniques are utilized to provide consistent quality. Good working knowledge of all areas of Appeals. Monitor new medical bill issues and billing trends and report to next level management. Research and report system issues. Work with next level management to establish and implement staffing strategy. Implement strategies and initiatives to improve appeals review quality and productivity. Using multiple screens on the Medical Bill Re-pricing System to investigate and resolve escalated provider calls and medical appeals Create and deliver performance reviews Coach, monitor and facilitate the development of team members to maximize individual and organization performance Evaluate and manage performance objectives relative to quality, productivity & other office standards/goals as well as providing individual team feedback on an ongoing basis Recognize all factors of performance, business results & personal effectiveness EDUCATION/COURSE OF STUDY: Bachelors degree preferred and /or equivalent work experience WORK EXPERIENCE: Proven ability to lead a team of analysts in a high quality/ high production environment. Certified Coder preferred or commensurate experience with the following resource materials; Current Procedural Terminology, International Classification of Diseases-9 Revision, Healthcare Common Procedural Coding System- 9th Revision, itemized hospital bills and other hospital records. Certified California Medical Bill Reviewer a plus. Knowledge of Workers Compensation claim process and procedures, preferred. Good working knowledge of human anatomy and medical terminology preferred. Strong interpersonal communication skills. Excellent verbal and written communication skills, including effective sentence construction, grammar, spelling, and punctuation. Solid math skills - must be able to quickly and accurately add, subtract, multiply and divide with the assistance of a calculator. Basic computer skills - ability to toggle between screens to find data that is needed to process medical bills and working knowledge of Microsoft Office products (e.g. Excel, Power Point, Word, Outlook). Ability to understand business drivers and effectively communicate business decisions.

OTHER: Good leadership skills. Strong analytical skills Ability to perform and be flexible in a high production environment Ability to handle multiple tasks. Superior Organizational Skills and Attention to Detail Commitment to Task Continuous Learning Strong decision making and problem solving skills. Ability to think issues through to conclusion, weighing the benefits and risks effectively. Sense of urgency Ability to deliver performance objectives in a timely manner. Travelers is an equal opportunity employer. We actively promote a drug-free workplace.

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Medical Bill Provider Appeals Job - Travelers Insurance - Tampa, FL

Medical Bill Provider Appeals Job more... ?

Medical Bill Provider Appeals Job Apply now Date: Oct 4, 2011 Location: Tampa, FL, US Solid reputation, passionate people and endless opportunities.That's Travelers. Our superior financial strength and consistent record of strong operating returns mean security for our customers - and opportunities for our employees. You will find Travelers to be full of energy and a workplace in which you truly can make a difference.

SUMMARY: Under general supervision this position is responsible for examining and evaluating previously paid moderate to complex medical bills, based on additional information submitted by medical providers, to determine and generate correct payment. Responding to escalated calls from medical providers regarding payment decisions for medical services. Responsible for keeping abreast of rules, regulations and contracts that are continuously changing.

PRIMARY DUTIES: Perform a detailed review of previously submitted medical, hospital, durable medical equipment, pharmacy, home health et al bills along with accompanying reports/information for accuracy and to determine appropriateness.Using multiple screens on the Medical Bill Re-pricing System, read and interpret scanned medical reports to determine that services on bill were actually performed and coded to reflect the services that were actually Providedpare bill and rates with appropriate fee schedules, clinical edits, Medicare, National Correct Coding Initiative (NCCI), internal Travelers protocols and PPO contracts to determine whether additional payment is due or if recovery of overpayment is Necessarypile all medical bills to determine if there is overlap or duplication of any services.Apply payment policies to medical supplies and drugs/ medicine.Make accurate payments to medical providers based on the results and analysis of each medical bill.If original decision will be upheld, develop a formal response with supporting documentation. Commence recovery measures, when overpayment has occurred.Serve as the liaison between the provider and company including department leadership, Travelers Claim Product team and third party vendors.Regularly and independently identify and bring to management-s attention any unusual/new medical procedures or billing anomalies identified during the review.In addition to day-to-day responsibilities, participates on high volume special projects in support of the New Product team.Deliver superior customer service to Travelers Claim professionals and those medical providers with escalated issues. Answer questions and analyze and resolve problems.EDUCATION/COURSE OF STUDY: College degree preferred and /or equivalent work experience Previous Appeals experience reviewing workers compensation medical bills highly desirable.CERTIFICATES/DEGREES: Certified Coder preferred or commensurate experience with the following resource materials: Current Procedural Terminology (CPT) International Classification of Diseases-9 (ICD-9) Revision Healthcare Common Procedural Coding System - 9th Revision (HCPCS) codes Itemized hospital bills, hospital records.Certified California Medical Bill Reviewer a plus.

COMMUNICATION SKILLS: Solid customer service telephone skills.Strong interpersonal communication skills.Strong verbal and written communication skills, including effective sentence construction, grammar, spelling, and punctuation.

COMPUTER SKILLS: Basic computer skills: ability to toggle between multiple screens to find data that is needed to process medical bills. Proficiency in Microsoft Office products (e.g. Excel, Power Point, Word, Outlook).

OTHER: Good working knowledge of human anatomy and medical terminology preferred Working knowledge of Workers Compensation processes and procedures including fee schedule and payment rules preferred.

Solid math skills: must be able to quickly and accurately add, subtract, multiply and divide with the assistance of a calculator.Proven ability and interest in staying abreast of new and emerging medical trends and literature.Strong attention to detail and ability to independently read and comprehend completely the details of a medical bill/report and notes and assess them against all appropriate rules and protocols.Strong comprehension and analytical skills Ability to produce high quality results in a high production environment Superior Organizational Skills and Attention to Detail Commitment to Task Continuous Learning Decision Making and Problem Solving skills.Decisiveness Sense of urgency Flexibility Travelers is an equal opportunity employer. We actively promote a drug-free workplace.

Job Category: Claim Nearest Major Market: Tampa Job Segments: Customer Service, Healthcare, Human Resources, Medical, Medical Equipment, Medicare, Pharmacy, Workers Compensation

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