Mercyhealth Wisconsin and Illinois

Medical Billing and Coding

• Reviews, analyzes, and interprets documentation and identifies discrepancies between the code selection and the documentation; corrects them, and presents findings and education to the appropriate partner.
• Resolves pre-bill claim edits from all areas and as identified by claims scrubbing software.
• Maintains a close working relationship with departmental staff, frequently querying them and providing education when coding discrepancies arise.
• Researches and provides education to all partners regarding CMS policies related to outpatient coding, inpatient coding, and professional fee coding, and presents findings to them.
• Solves complex billing and claim denial issues related to coding by researching policies and guidelines.
• Demonstrates extensive knowledge of official coding guidelines established by the American Medical Association (AMA), the Center for Medicare & Medicaid Services (CMS) and contracted payers.
• Has a thorough understanding of the differences between professional coding in a clinic setting as compared to professional coding in a hospital setting (outpatient and inpatient), and demonstrates a high skill level in the practical application of that knowledge.
• Maintains an in-depth knowledge of Epic billing, ambulatory, and hospital modules.
• Responds to customer concerns through coding reviews requested by other departments.
• Assists with all coding functions at or above the level of a Medical Coding 1 job description.
• Works as a team to achieve productivity goals.

Medical Coding Technician

Billing Specialist

• Verifies claims are received by the payer and follows up to obtain payment via phone calls, portal or website use.
• Reviews claim adjustment reason codes or explanations of benefits received by the payer to determine what reasons for denials records are indicating for appropriate follow-up.
• After denial review, evaluates next steps and takes action to call payer, follows up with a resubmission or dispute/appeal/reconsideration as required by payer, or works internally to receive payment on account.
• Drafts an appeal or complete reconsideration forms when applicable based on payer requirements in a format that is logical and relates to the open denial of payment.
• Obtains and sends medical records during the appeals process when needed to substantiate medical necessity.
• Ability to review billing forms for both paper submissions and electronic submissions for accuracy.
• Calls patients or payers directly without hesitation to obtain needed information to resolve an account balance when applicable.
• Identify trends with payor rejections or denials and escalates these trends to leads/supervisors.
• Uses computer systems/technology to locate claims information to resolve account balances.
• Maintains compliance with patient financial services policies and procedures.
• Uses fax machine and other office equipment during the course of normal daily operations.
• Reviews accounts based on patient or departmental inquiries.
• Also, works and follows up with other Mercyhealth departments in a timely fashion if outstanding questions are not resolved and a claim is in jeopardy of not being paid.
• Interacts with other Patient Financial staff members to provide pertinent information, which may include training and document sharing , and to ask for guidance to resolve knowledge base deficiencies.
• Researches accounts at a higher level that are denied for No Authorization as a priority in the attempt to appeal or escalate to Precertification department if a retro authorization may be needed.
• Works billing functions when needed.
• Escalates high dollar accounts for a second level appeal if needed.
• Reports equipment malfunctions and supply needs, as necessary.
• Accesses available resources, such as the patient accounting system, biller files, other areas in the Revenue Cycle, or payer databases, to locate missing or incorrect information.
• Apply creative problem-solving skills in order to overcome obstacles and resolve errors for claim adjudication.
• Coordinates with management and external departments to resolve unresolved accounts and potentially create process redesign initiatives for long term root cause resolution.
• Completes special projects as assigned.
• Maintains a comprehensive awareness of all insurance company updates including Federal and State guidelines.
• Meets productivity goals as assigned by the Revenue Cycle Director.

Insurance Billing Representative, Patient Accounts

Analyst

• Performs moderate to advanced application maintenance as needed in support of requested changes.
• Updates and maintains required documentation and issues lists.
• Able to provide moderate to advanced levels of design and support.
• Consult with the vendors when needed.
• Conducts continual assessment of operational/technical needs and workflow analysis in order to recommend and build optimal screen flows to ensure successful implementation, administration, and documentation of new and existing applications.
• Requires process and application expertise and strong leadership skills to work with key personnel, end users, and project team members to identify and resolve issues throughout project phases of assessment, design, build, testing, training, and implementation.
• Will accept and complete new project assignments and will sometimes be asked to lead a project.
• Participation typically involves workflow analysis, design, general systems analysis, and development of a functional specification, creation of a test plan, testing and documentation and implementation for new or existing applications.
• Responsible for appropriately communicating project status and resolving and/or escalating issues where appropriate.
• Knowledgeable in multiple applications and has in-depth knowledge of how the supported applications integrate with each other and has a strong level of expertise in an individual application.
• Responsible for understanding applicable regulatory requirements and can work with operations to suggest and implement requirements.
• Knowledge of applicable interfaces and integration, basic to moderate troubleshooting skills.

System Analyst – Rev Cycle

Business Intelligence Developer

• Provide business intelligence support for MercyCare’s Actuarial and Underwriting department along with other MercyCare directors, managers and clients in making informed business decisions based on past and present data collected, curated, reconciled and reported from all available data sources.
• Maintenance and extraction of information from the data warehouse and other data sources with an emphasis on creating reports and visualizations for management.
• Monthly reconciliation with Finance of key control totals underpinning loss ratio reporting along with assistance in the reconciliation of reports developed outside of MercyCare (by MHS).
• Annual maintenance of risk adjustment scoring algorithm and monthly updates of MercyCare risk scores to support reserving.
• Support prioritization of pended claim processing during Q1 of each calendar year for risk adjustment optimization.
• Assist Finance in the completion of Medicaid financial reporting.
• Monthly updating of enrollment and loss ratio budget vs. actual along with an analysis of variance.
• Support or completion of certain regulatory financial surveys, such as the EDGE Server baselines, NAIC survey and the 1332 Waiver survey.
• Auditing of operations as needed, such as an investigation of duplicate claims, Medicaid pricing or fee schedule analysis.
• Support of monthly commercial reinsurance notification and filing process.
• Development of utilization and cost trend reporting.
• Creation of data sets supporting ACA Single Risk Pool pricing and end of year Statement of Actuarial Opinion.
• Extraction and initial preparation of large group experience-rated renewals.
• Creation of additional meaningful utilization reports for large group clients.
• Staging of data for ad hoc actuarial studies.

Business Intelligence Analyst

Insurance

• Acts as a lead specialist to provide project, program and /or initiative-related direction and guidance for other specialists within the department and/or collaboratively with other departments.
• Assists in monitoring and analyzing outcomes to ensure goals, objectives, outcomes, accreditation and regulatory requirements are met.
• Program and support Microsoft Access databases to manage targeted disease populations and provide efficiencies in work processes.
• Design and implement strategies for outcomes improvement based on membership population characteristics and business functions requirements.
• Participate in the implementation of Continuous Quality Improvement activities by contributing front line knowledge of projects and observations.
• Develop optimal alternative solutions based on feedback and environmental analysis.
• Implement process improvement using innovative thinking, root-cause-analysis, process mapping, and charting techniques.
• Complete Quality Initiative projects according to specifications and requirements.
• Provide follow up and education of providers and clinic staff on measures and project objectives.

Quality Improvement Specialist

Learning and Development

• Assists in the design, development and coordination of training sessions, programs and competency testing for Revenue Cycle Operations.
• Prepares, assembles and revises course materials annually or as requested to meet department needs.
• Achieves and maintains a solid understanding of the business environment as a whole, including business practices, processes and strategies.
• Conducts training, development, competency testing and general orientation sessions for partners in all areas of Revenue Cycle including Patient Access, Patient Financial Services, Managed Care and Coding.
• Assists in evaluation of effectiveness of training programs.
• Develops presentation materials, leads meetings and facilitates workgroups.
• Maintains master training calendar, ensure availability of equipment, space and materials.
• Prepares course advertising materials; coordinates schedule of external and internal training resources.
• Communicates all set-ups of training sessions and ensures necessary materials and supplies are available.
• Follows-up with staff in-person after completion of training to ensure competency or retraining as necessary.
• Works with management team to provide additional support including coaching and in-services.
• Facilitates, and measures regular quality audits across the Revenue Cycle areas to ensure areas meet organizational objectives; Conducts quality audits and provides feedback to division leadership.
• Provides analysis of the quality metrics and updates on Revenue Cycle dashboard.
• Identifies and facilitates lean initiatives for areas that fail to meet performance metrics.
• Demonstrates collaboration and flexibility to deliver education when most convenient for the department.
• Partners with information systems to test all EPIC upgrades for Revenue Cycle areas with keen understanding of changes and impacts to revenue cycle processes.
• Documents department workflows and inter-departmental impacts via Visio workflow documentation.
• Identifies opportunities for improvements during workflow documentation and notifies leadership of such opportunities.
• Creates and maintains workflow documentation and training materials in a central storage location to allow partner accessibility when needed.
• Partners with all team members to achieve goals.
• Remains receptive to others' ideas and opinions.
• Performs other duties as assigned.

Training Specialist, Revenue Cycle

• Serves as A Subject Matter Expert-SME with regards to the insurance follow-up processes.
• Conducts and manages all department workflow training for new hires.
• Escalates and follows-up with various Mercyhealth departments on any open and unresolved items.
• Monitors and works interdepartmental communication work queues.
• Investigates and works identified payor trends.
• Develops written workflows and job aids to help provide additional resources to Follow-Up Representatives.
• Assists with the review and approval of department adjustment requests.
• Researches and provides ongoing partner education regarding regulatory compliance and requirements for claim submission.
• Ensures accurate and timely completion of daily tasks and projects.
• Performs partner audits on a regular basis to ensure quality and accuracy of partner work product.
• Provides daily support to work group partners.

Team Lead, Insurance Billing

Operations

• Utilizes the nursing process and collaborates with interdisciplinary team members in caring for patients.
• Administers prescribed medications and treatments in accordance with approved nursing techniques, policies and procedures, standards of care, and State laws practice act.
• Documents according to standards of care.
• Performs assessments, planning, intervention, and evaluation of care.
• Develops, initiates, and executes a patient plan of care according to the individualized needs of the patient, as prescribed by Physician and or clinic policy including patient and family instruction.
• Participates in department or unit performance improvement activities, may include shared governance.
• Utilizes clinical expertise and guidance to other units’ departments in support of the patient’s longitudinal plan of care.
• Utilizes critical thinking regarding patient safety and patient experience and appropriately escalates to the appropriate chain of command.
• Participates in the professional nursing continuum process, unit practice activities and decisions and peer review process.

Registered Nurse – PACU / OPS

• Interpret and understand coverage and benefit limitations by having a comprehensive understanding of benefits and state requirements for multiple markets.
• Identify trends and suggest and develop efficiencies in the revenue cycle through review and trending of payer contracts and reimbursement trends.
• Research and trends denials from payors.
• Reads through healthcare contracts and contract language and ensures proper contract workflows.
• Researches remittances and Explanation of Benefits (EOBs) for complete accurate payments or denials.
• Work with payers to understand specific reasons for variances and/or denials and measures to prevent future denials.
• Research payer policies and requirements and utilize knowledge to determine whether an appeal is required and to get claims overturned.
• Develop sound and well-supported appeal arguments, where an appeal is warranted.
• Submits corrected claims and appeals.
• Coordinates appeals with clinical or coding areas within the revenue cycle.
• Requests appropriate adjustments, when required.
• Provide training and guidance to team members on market specific issues by providing feedback to management on claims and provider issues, and updating client business rules.
• Partner with Reimbursements team to assist in completing all other tasks as necessary to ensure accurate and timely internal turnaround times.

Revenue Cycle Reimbursement Analyst

• Performs moderate to advanced application maintenance as needed in support of requested changes.
• Updates and maintains required documentation and issues lists.
• Able to provide moderate to advanced levels of design and support.
• Consult with the vendors when needed.
• Conducts continual assessment of operational/technical needs and workflow analysis in order to recommend and build optimal screen flows.
• Requires process and application expertise and strong leadership skills to work with key personnel, end users, and project team members to identify and resolve issues throughout project phases.
• Will accept and complete new project assignments and will sometimes be asked to lead a project.
• Responsible for appropriately communicating project status and resolving and/or escalating issues where appropriate.
• Knowledgeable in multiple applications and has in-depth knowledge of how the supported applications integrate with each other.