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Payor Operations Eligibility Business Analyst
at RadNet
Baltimore, MD

Payor Operations Eligibility Business Analyst
at RadNet
Baltimore, MD

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Job Description

 This position will be part of a Payor Operations team designed to work with leadership in each local market, including the National Payor Database (NPD) team, Directors of Contracting, Insurance Verification, Patient Service Representatives, Clinical Operations, Reimbursement Operations and Strategic Initiatives. This position will also interface with Reimbursement Operations, Credentialing, IT and RIS system support teams, to deliver accurate and timely analytical insight to ensure effective outcomes in eligibility determination and billing cycle. This position will be responsible for the installation and administration of payor insurance codes including structure and billing set up, eligibility collection, database loading, and preparation of insurance plan educational materials/guides. The position will also be responsible for creating the overall payer workflow and processing various databases to maximize accuracy in determining cost shares and collections at Time of Service. Additionally the Payer Operations Eligibility Analyst will help in the reconciliation of account receivable management that has been sent to the Contracting Tickler file via the Managed Care payer claim file.

Duties and Responsibilities

  • Positions in this function are responsible for preparing, processing and maintaining member or group payer insurance code designations. Position is also responsible for reconciling eligibility discrepancies identified by error reports, and/or internal staff members analyzing transactional data, and submitting retroactive eligibility changes. Sr. Team Members may have the ability to load member or group data into the eligibility database & update the database with changes. Position also responds to member eligibility or group questions and verifies enrollment status. Position will be main point of contact in regards to determining eligibility enrollment related items. Position will answer incoming phone calls from customers (members, providers, groups), provide expertise and support to customers, and practice superior customer service skills in all lines of communication while adhering to departmental expectations for answering calls and providing excellent customer service while tracking via smart sheet technology.
  • Serve as primary contact as it relates to all eligibility enrollment tasks for assigned payer book of business, which include multiple internal and external group customers; maintain satisfied customers by providing superior service with consistent feedback on pending inquiries, and practice attention to detail in various responsibilities
  • Follow established procedures to maintain eligibility enrollment data in applicable systems and databases based on payer requirements, plans and products. Create and/or request static electronic file, or internal reports; seek guidance from superiors (mentor, team - lead, supervisor) for non - standard enrollment inquiries during bi-weekly standing calls with our Information Technology Admins. Track for discussions field findings for trending, corrective actions, and process improvement with overall documented education back to all support teams in a designated timely fashion.
  • Read, interpret, and communicate eligibility requirements following plan guidelines
  • Practice advanced follow - up skills with internal and external parties to ensure group customer expectations are attended to and that member data is accurately reflected in enrollment system at all times
  • Review moderately complex error reports, analyze payer and member eligibility enrollment data, and correct eligibility enrollment system(s) based on findings.
  • Resolve customer inquiries as they relate to eligibility through all lines of communication, including e - mails and phone calls; provide customer service in a friendly and professional manner to internal / external parties; document call details in applicable system
  • Serves as liaison between Managed Care, Reimbursement Operations and Information Technology to provide immediate and effective resolution to issues affecting payer operations to improve revenue cycle management.
  • A complete understanding of eligibility benefits and the 270/271 service type and taxonomy identification and assignment process.
  • Provides the most efficient communication to health plans to ensure maximum level of reimbursement.
  • Interacts with health plan personnel to educate and influence their decision related to medical management recommendations for approval of reimbursement.
  • Assists in the identification, validation, generation, and documentation of moderate to complex recovery claims projects through thorough data analysis.
  • Data research will involve extensive use of RadNet applications to determine reimbursement and revenue cycle management.
  • Maintains open dialogue with key stakeholders keeping all lines of communication open with the utmost transparency.
  • Coordinates with appropriate team(s) to ensure that payor initiated modifications to include fee schedule, coding, billing and claim issues are implemented and payer-related issues are resolved.
  • Multitasking while maintaining a high level of efficiency and sense of urgency.
  • Works directly with office/facility or field Directors if additional information is required to proceed with the matter at hand.
  • Identifies areas of process improvement and provides recommendations.
  • Attends and participates in regular business team meetings.

Education and Experience Requirements

  • Graduation from a four (4) year college or university with a degree in Healthcare Administration, Business Management or related field required.
  • At least seven years of experience in health care collections, A/R management, insurance verification, appeals negotiations and processing in the health care industry, health care billing/claims processing, and data processing and software operations in the health care industry.
  • Requires a comprehensive understanding of commercial, Medicare and Medicaid health plans.
  • Extensive knowledge of radiology medical coding, CPT and HCPCS codes and ICD 10.
  • Comprehensive understanding of medical management and health insurance concepts, information management systems and strong analytical and problem solving skills are required.
  • Strong Excel data analysis skills and proficiency with Microsoft Office applications. Will be required to pass with 80% proficiency an Intermediate Excel assessment.
  • Strong written, verbal and interpersonal communication skills

Company Description

RadNet is the National Leader in outpatient imaging. Backed by 30 years of experience, we deliver high-quality, cost–effective solutions for all 340+ centers in our network and for our strategic partners.

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