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.
Valuable 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, advantage 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.