The Patient Communications Representative is responsible for managing medical accounts by contacting patients to secure payments or establish payment arrangements. They must also resolve patient inquiries, update account information, and ensure all activities comply with federal and state regulations.
The Medical Reimbursement Specialist is responsible for resolving outstanding medical claims through research, follow-ups, and appeals with insurance carriers. They must also maintain accurate patient accounts and edit rejected claims in accordance with Medicare regulations.
Manage the end-to-end authorization process, including notification, submission, and follow-up with payers to ensure timely determinations. Act as a liaison between hospital staff and health payers while maintaining accurate documentation in EMR and internal systems.
The DRG Revenue Integrity Auditor performs validation and quality audits on inpatient medical records to ensure accurate coding and reimbursement. They also support Clinical Documentation Integrity programs and maintain compliance with federal regulations and clinical standards.
The Charge Capture Analyst will assess and document charge capture workflows while managing Epic or Cerner system builds to ensure compliance. They will also collaborate with clinical and billing teams to refine CDM processes and provide training to hospital staff.
The Team Lead oversees quality assurance, report creation, and educational delivery while acting as a liaison between leadership and the auditing team. They are responsible for maintaining audit playbooks, training staff, and ensuring compliance with coding guidelines.
The Coding Specialist will provide professional fee, facility, or HCC coding services across various medical specialties. They are responsible for accurately assigning diagnosis and procedure codes while maintaining high productivity and quality standards.
The Clinical Quality Reviewer performs comprehensive clinical reviews of prior authorization requests to ensure medical necessity and regulatory compliance. They also validate documentation accuracy, support physician determination activities, and collaborate with cross-functional teams to optimize review workflows.
The Clinical Review Specialist reviews medical records for medical necessity, level of care, and authorization compliance to ensure alignment with payer guidelines. They are responsible for preparing and submitting high-quality appeals for clinical denials while maintaining documentation standards and meeting turnaround times.
The coordinator will manage payer communications to schedule and follow up on Peer to Peer calls while documenting case statuses in proprietary systems. They will also support various departmental functions including case entry and appeals processing.
Perform complex concurrent and retrospective medical record audits to validate coded data against official guidelines. Develop and deliver educational content to clients based on audit findings to improve coding accuracy and compliance.
Healthcare auditors review hospital claim data and insurance contracts to identify reimbursement issues and underpayment risks. They develop audit plans, model reimbursement methodologies, and provide actionable recommendations to improve financial recovery.
The Insurance Specialist is responsible for identifying and resolving hospital and professional insurance claim denials and processing errors. They will leverage proprietary software, phone calls, and web portals to ensure accurate claim resolution while maintaining compliance with HIPAA regulations.
Perform concurrent clinical case reviews to establish appropriate admission status and provide recommendations to client hospitals. Identify process improvements and inefficiencies while interacting with attending physicians to ensure compliance and appropriate payment.
The Clinical Review Specialist performs medical necessity and level of care reviews for inpatient and outpatient services to ensure authorization compliance. They are responsible for identifying documentation gaps, supporting appeal submissions, and maintaining quality standards according to payer guidelines.
The HCC Coding Quality Specialist is responsible for auditing HCC coded records to ensure accuracy and compliance with Medicare and ICD-10-CM guidelines. They also provide feedback to coders, assist with training materials, and maintain high quality and productivity standards.
The Patient Services Representative is responsible for completing patient registration, verifying health plan coverage, and obtaining necessary authorizations. They must maintain accurate documentation in hospital systems while ensuring compliance with federal and state regulations.
Resolve complex unpaid or denied claims for long-term care and skilled nursing facilities while ensuring compliance with federal and state billing regulations. Coordinate with clinical and finance teams to optimize reimbursement through accurate coding and timely claim submission.
Leads the internal pre-bill DRG validation program to ensure coding accuracy and compliance prior to claim submission. Responsible for designing the quality assurance framework and managing the training and education infrastructure for coding and CDI staff.
The Medical Director reviews clinical records and case files to ensure Medicare services comply with CMS regulations and clinical guidelines. They also lead peer-to-peer discussions with providers regarding prior authorization requests and drive quality improvement initiatives.
Review and analyze patient medical records to abstract ICD-10 codes specifically mapping to HCC, RxHCC, and ESRD models. Ensure compliance with Medicare guidelines, client-specific requirements, and privacy regulations.
Responsible for reviewing and resolving outstanding insurance balances on hospital or physician patient accounts to meet cash recovery goals. This includes performing account research, preparing payment appeals, and ensuring compliance with federal and client guidelines.
Resolve complex unpaid or denied claims for long-term care and skilled nursing facilities while ensuring compliance with federal and state regulations. Coordinate with clinical and finance teams to optimize reimbursement through accurate coding and timely claim submission.
The Revenue Analyst investigates incorrectly paid medical insurance claims and pursues underpayments through correspondence with insurance companies. They analyze payer contracts, identify revenue risks, and mentor new team members while managing internal projects.
The role focuses on auditing medical documentation for coding accuracy and performing root-cause analysis on insurance denials to maximize reimbursement. It involves collaborating with physicians to improve documentation specificity and ensuring compliance with medical coding guidelines.
Performs complex retrospective analysis of medical records to identify coding and billing errors while ensuring compliance with legal and procedural policies. Provides technical support, training, and quality assurance monitoring for internal coding staff to optimize reimbursement.
Collaborate with healthcare providers to improve the accuracy, specificity, and completeness of clinical documentation for outpatient encounters. Review medical records to ensure valid DRG assignment, risk adjustment, and compliance with regulatory guidelines.
Perform accurate analysis of medical records to assign appropriate ICD-10, CPT, and HCPCS codes across multiple specialties. Maintain high quality and productivity standards while ensuring compliance with ethical coding standards and privacy regulations.
The Medical Director will assess the quality of clinical services provided to Medicare beneficiaries, ensuring compliance with clinical guidelines and regulations after mentored training. Daily work involves reviewing clinical records to ensure practices meet the highest standards of care and adhere to CMS policies.
CDI Specialists will collaborate with healthcare professionals to improve the quality and accuracy of clinical documentation. They will conduct chart reviews and issue queries to ensure compliance with documentation standards.
