Reconcile assigned accounts, maintain accurate general ledger accounts, and prepare or process journal entries and accounting records. Analyze financial data and variances, conduct quality reviews of overpayments, and support financial reporting, filings, forecasting, budgeting, and special projects.
Review medical claims and clinical information using established criteria and guidelines to determine medical necessity, appropriateness, coverage, and reimbursement. Document decisions, support quality and timely review processes, educate staff, and provide guidance to LPN team members.
Performs medical claim reviews to determine medical necessity, appropriateness, and coverage based on established clinical guidelines. Documents medical rationale for payment or denial decisions and provides guidance to internal staff regarding medical terminology and coding procedures.
Perform medical claim reviews to determine medical necessity, appropriateness, and coverage based on established clinical guidelines. Document rationales for payment or denial and provide education to internal and external staff regarding medical review processes.
The consultant provides education to medical providers regarding Medicare coverage, utilization statistics, and documentation requirements. They also conduct formal educational workshops and analyze reports to determine appropriate actions for providers with high error or denial rates.
The consultant educates medical providers on Medicare coverage, documentation, and utilization statistics through formal workshops and direct communication. They also analyze provider billing data to identify over-utilization and coordinate with the medical review department to address program abuse.
Develops and delivers educational materials and training sessions for network providers, physicians, and referral agents. Acts as a liaison between the organization and state or federal agencies to resolve issues and ensure training needs are met.
The Appeals Analyst researches complex appeal and retrospective review requests to determine medical necessity based on clinical documentation and contractual requirements. They document decisions accurately while ensuring compliance with applicable regulations and confidentiality standards.
The Medical Director provides administrative oversight to medical staff, analyzes utilization data, and develops claim adjudication criteria. They also research new medical procedures and act as a liaison between the company and the medical community.
The Medical Director provides administrative oversight to medical staff, analyzes utilization data, and develops claim adjudication criteria. They also act as a liaison between the company and the medical community while researching new medical procedures and technologies.
The Molecular Diagnostics Medicare Medical Director oversees medical staff, analyzes utilization data, and researches emerging molecular technologies. They also develop and revise medical policies to ensure compliance and support Medicare coverage decisions.
