Healthcare Outcomes Performance Co. (HOPCo)

Insurance

• Reviews insurance denials and rejections to determine the next appropriate action steps and obtain the necessary information to resolve any outstanding denials/rejections.
• Verifies patient demographic information and insurance eligibility including coordination of benefits; updates and confirms as necessary to allow processing of claims to insurance plans.
• Verifies receipt of claim with insurance plans, determining the next appropriate action steps and timeliness of claims maximum reimbursement.
• Researches all information needed to complete the billing process including obtaining information from providers, ancillary services staff, and patients.
• Obtains and attaches referrals/authorizations to appointments/charges.
• Maintains productivity and accuracy metrics per department expectations and AEIOU Behavioral Standards.
• Assumes full responsibility for reducing the accounts receivable of insurance balances by working through outstanding accounts.
• Analyzes account for proper claims processing and payment posting through inquiries from patients or staff.
• Identifies and communicates trends and/or potential issues to the management team.
• Follows and maintains all HOPCo policies and procedures, including those specific to billing and the Revenue Cycle.

Insurance Follow Up, Medical Biller

• Reviews insurance denials and rejections to determine the next appropriate action steps and obtain the necessary information to resolve any outstanding denials/rejections.
• Verifies patient demographic information and insurance eligibility including coordination of benefits.
• Updates and confirms as necessary to allow processing of claims to insurance plans.
• Verifies receipt of claim with insurance plans.
• Determines next appropriate action steps and timeliness of claims maximum reimbursement.
• Researches all information needed to complete the billing process including obtaining information from providers, ancillary services staff, and patients.
• Obtains and attaches referrals/authorizations to appointments/charges.
• Maintains productivity and accuracy metrics per department expectations and AEIOU Behavioral Standards.
• Assumes full responsibility for reducing the accounts receivable of insurance balances by working through outstanding accounts.
• Analyzes account for proper claims processing and payment posting through inquiries from patients or staff.
• Identifies and communicates trends and/or potential issues to the management team.
• Follows and maintains all HOPCo policies and procedures, including those specific to billing and the Revenue Cycle.

Insurance Follow Up Representative

Medical Billing and Coding

• Reviewing patient records, doctor's notes, and other relevant documentation to extract information about diagnoses, procedures, and treatments.
• Determine which diagnostic and procedural information is necessary for accurate coding of an authorization.
• Assign appropriate ICD-10, CPT, and HCPCS codes based on the information found in the medical records.
• Verifying the correctness of assigned codes, ensuring they align with coding guidelines and regulations, and identifying any discrepancies or errors.
• Communicating with physicians, clinical stakeholders and other teams such as surgical scheduling and authorization management to clarify any ambiguities in the documentation or coding.
• Ensuring the security and confidentiality of patient information as mandated by HIPAA.

Coding Specialist – Pre-Service

Customer Success Manager

• Serve as the primary RCM strategic partner for assigned markets and physician groups
• Monitor and analyze key performance indicators including charge lag, denial rates, AR aging, AR >90 days, and net collection rate
• Lead monthly and quarterly revenue cycle reviews with market leadership and providers
• Identify root causes of revenue leakage and assist in developing corrective action plans
• Drive reduction in controllable denials through payer-specific analysis and operational collaboration
• Partner with cross-functionally with key revenue cycle stakeholders to proactively identify and resolve issues impacting revenue integrity and reimbursement performance.
• Support new market onboarding and RCM ASA integrations
• Escalate systemic issues to executive leadership with proposed solutions
• Participate in cross-functional revenue cycle initiatives and performance improvement projects

RCM Success Manager

Research Scientist

• Assist with clinical studies
• Maintain research databases
• Coordinate patient documentation
• Support research activities for patients and providers
• Communicate with clinical staff and patients/families
• Perform various record keeping tasks
• Complete necessary surveys for patients

Research Assistant

• Reviews, interprets, and abstracts clinical documentation from inpatient and outpatient hospital records
• Codes complex orthopedic surgical cases across multiple subspecialties
• Applies appropriate DRG and/or APC assignment methodologies
• Ensures coding accuracy and compliance with regulations
• Utilizes hospital EMR and coding systems to capture required clinical and demographic data
• Collaborates with physicians and clinical staff for documentation improvement
• Meets or exceeds established productivity and quality benchmarks

Facility Coder II

Clinical Operations

• Oversee the daily operations of the continuum of surgical services and med-surg nursing departments.
• Supervise nursing and support staff.
• Ensure proper staffing levels by assisting with scheduling, assignments, and workload distribution.
• Monitor and evaluate patient care practices.
• Mentor, coach, and provide ongoing education and training to OR nursing staff.
• Participate in quality assurance and process improvement initiatives.
• Assist in incident investigations and implementation of corrective actions.

Clinical Operations Supervisor

Director

• Develop and maintain positive, effective relationships with internal and external customers and serve as the contracting liaison between contracted Payors and providers.
• Conduct contract analysis and negotiations with Payors on behalf of providers including rates, payment methodologies, contract language and value- based payment programs in accordance with internal control processes for contract review, approval and signature.
• Participate in Payor reimbursement analysis that can be routinely updated and maintained as a baseline for strategies to maximize health plan reimbursement.
• Research and make recommendations to executive leadership in regard to payor contracting opportunities in new and existing geographic service area.
• Ensure compliance in all business and contractual relationships
• Identify and communicate trends and/or potential issues to management team.
• Other duties and responsibilities as assigned.

Director, Payor Contracting

Accounting Manager

• Own accounting activities related to value-based care, risk-sharing, capitated, and managed care arrangements.
• Execute the full month-end close for assigned VBC entities, contracts, and joint ventures.
• Own the accounting for IBNR and claims payable related to VBC arrangements.
• Perform accounting across multiple legal entities and ERP systems used for VBC operations.
• Prepare monthly financial statements and variance analyses for VBC entities.

Manager, Value Based Care Accounting

Billing Specialist

• Responsible for working claim errors in claims management system ensuring clean claims are submitted timely to insurance carriers.
• Review and prepare claims for manual and/or electronic billing submission.
• Reviews insurance rejections to determine the next appropriate action steps and obtain the necessary information to resolve any outstanding rejections.
• Correct and identify billing errors and resubmit claims to insurance carriers.
• Update CAS segments on secondary electronic claims as needed.
• Verifies patient demographic information and insurance eligibility including coordination of benefits; updates and confirms as necessary to allow processing of claims to insurance plans.
• Verifies receipt of claim with insurance plans, determining the next appropriate action step.
• Researches all information needed to complete the billing process including obtaining information from providers, ancillary services staff, and patients.
• Obtains and attaches referrals to appointments/charges.
• Maintains satisfactory productivity rates and ensures the timeliness of claims reimbursement while maintaining work queue goals.
• Identifies and communicates trends and/or potential issues to the management team.
• Follows and maintains all HOPCo policies and procedures.