Job Description - Credit Balance Analyst (240000QW)
Description
Responsible for timely research and resolution of insurance credit balances on highly complex cases. Performs necessary functions to refund overpayments from insurance carriers within 30 days of receipt. Manage work queues related to insurance overpayments and insurance credit balances. Identify trends, potential resolutions and escalate to manager. Evaluate accuracy of contract modeling, communicate findings, and escalate as appropriate. Responsible for reporting state Medicaid's credit balances on a quarterly basis. Participate in payer meetings to resolve issues. Responsible for ensuring solutions implemented and goals achieved. Identify and monitor CMS & payor rule changes and work to ensure compliance.
Qualifications
Minimum Education
Bachelor's Degree (Preferred)
Minimum Work Experience
3 years Related patient accounting experience required, especially related to insurance overpayments trending and root cause analysis (Required)
Required Skills/Knowledge
Excellent working knowledge of complex contract reimbursement methodologies including transplant, global, APR DRGs among others.
Proven analytical skills including ability to make recommendations based on financial analysis.
Excellent PC skills including advanced skill proficiency in Access and Excel spreadsheet analysis.
Ability to work in a team environment with other analysts, managers, and department leaders.
Proficiency in presentation of analytical results.
Excellent working knowledge of coding & NCCI edits.
Demonstrated knowledge of managed care payer requirements in an acute hospital setting.
Demonstrated ability to facilitate team or group activities.
Excellent verbal and written communication skills.
Demonstrated ability to be flexible and to prioritize workload & decision-making skills.
Ability to analyze workflow for process improvement.
Strong organizational and coordination skills required.
Functional Accountabilities
- Account Follow-up
- Ensure all assigned claims and encounters are reviewed in a timely manner as per standard operating procedure (SOP).
- Evaluate contract management expected reimbursement and follow appropriate guidelines to report and escalate discrepancies.
- Assess overpayments and process timely as per procedures.
- Rebill claim or issue refund as appropriate to facilitate payment retraction or refund.
- Establish a system to ensure refund requests from insurance carriers are processed within 30 days of receipt.
- Read and interpret payer contracts for accuracy when submitting refund request for approval.
- Ensure appropriate supporting documentation is included with refunds.
- Report state Medicaid’s credit balances on a quarterly basis.
- Data Analysis and Issue Resolution
- Manage matrix of issues & resolutions including accountable stakeholders; ensure results and escalate issues as appropriate; regularly report updates and challenges to manager.
- Conduct root cause analysis of issues affecting overpayments. Identify key issues and assist in tracking, trending and reporting.
- Present data and analysis clearly to all levels of staff and management.
- Meet with manager and outside departments to review issues and develop action plans.
- Assist in development of solutions, training & education guidelines to resolve issues and share data with staff and management.
- Appropriately engage and involve key accountable stakeholders in a collaborative manner.
- Research payer & CMS policies related to revenue cycle; identify & alert stakeholders of required changes; track and ensure completions.
- Organizational Accountabilities
- Maintain a refund request log to monitor the request, issuance, mailing and posting of refunds.
- Provide supporting documentation to Accounts Payable with completed signatures and back up.
- Organizational Commitment/Identification
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