Medical Review Analyst

Essential Functions:

• Consults with clinical departments on charge process. Ensures appropriate usage of billing mechanisms and process flow to optimize reimbursement through both coding and charge capture.
• Conducts random reviews comparing medical record documentation to validate charge capture.
• Identifies issues with medical necessity and coding that reduce reimbursement. Works with departments to improve the process.
• Investigates and recommends action steps and works collaboratively with the department to improve processes when control, operational weaknesses and /or compliance issues are found. Performs follow up reviews to ensure action steps were met.
• Ascertains compliance with established policies, plans and procedures as well as external regulations.
• Investigates billing system errors as a result of potentially inappropriate documentation, coding, medical necessity or charging. Follows through with the department to ensure corrective action.
• Investigates payers' denials and institutes appropriate course of action. Develop process improvement if internal review coincides with payer denials to ensure appropriate reimbursement.
• Works with billing and ancillary departments to resolve billing edits and billing inquiries.
• Works in conjunction with Financial Specialist when submitting for appeals for payer denials or requests for reduction in service.
• Interfaces with physicians, managers and staff in departments to ensure quality work product..
• Enters and/or retrieves data from established computer files using knowledge of various computer software applications.

Common Expectations:

• Maintains established policies and procedures, objectives, quality assessment and safety standards.
• Maintains professional growth and development.
• Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.
• Administers/coordinates programs, projects, and/or processes as assigned.