ESSENTIAL DUTIES AND RESPONSIBILITIES
- Conduct comprehensive utilization review activities for behavioral health services, ensure adherence to payer guidelines, medical necessity criteria, and regulatory requirements.
- Review and analyze clinical documentation, treatment plans, and patient records
- Collaborate with therapists, physicians and other clinical staff to obtain required information and ensure seamless continuity of care.
- Good understanding with EMR systems ifor documentation review, tracking, and utilization management.
- Manage prior authorizations through payer portals.
- Verify referrals/authorizations for denied procedures. Obtain and work with the practice to correct any referrals/authorizations for denied procedures.
- Checking insurance eligibility and perks for patients, as needed.
- Reviewing patient accounts for accuracy and completeness and obtaining any missing information.
- Ensure accurate submissions, benefit verification, timely follow-ups, and successful approvals.
- Following up on unpaid claims within standard billing cycle timeframe for the client and carrier.
- Checking each insurance payment for accuracy and compliance with contract discount, as necessary.
- Calling insurance companies regarding any discrepancy in payments if necessary
- Identifying and billing secondary or tertiary insurances.
- Reviewing accounts for insurance of patient follow-up including review and research of self-pay, refund accounts for insurance.
- Researching and appealing denied claims. Coding research appeals and corrections at the discretion of the client and management.
- Answering patient or insurance telephone inquiries pertaining to assigned accounts.
- Understand CPT codes and ICD-10 codes and when these can be changed or not.
- Understand the insurance carriers requirements for submitting claims and appeals.
- Understand special situations and procedures that relate to the specialty you work on.
- Performs other duties as assigned.