Re submission officer
Al Garhoud Private hospital
Total years of experience :11 years, 10 Months
Managing re-submission of denial claims with standard time frame and the policy guidelines
Analyzing rejected claims and resubmitting the same with proper justification and other information’s\[eligibility, authorization and non covered\]
Review the denial reasons and audit the claims in order to generate justification for the rejection.
Submit the audit report to finance team and generate the xml file and upload DHPO.
Prepare the rejection report and Submitting the KPIs of re-submission quarterly to higher management
Submitting the KPIs of re-submission quarterly to higher management
Giving updates to the doctor regarding the medical necessity rejection and requesting proper documentation to avoid rejections.
Review denial reasons and audit the claims in order to generate justification for re-submission.
Working closely with Insurance Approvals, Claims Submission and Reconciliation Team.
Regularly monitor health insurance-specific updates regarding policies and procedures.
Meet the re-submission productivity target on a daily basis efficiently and accurately.
Provides justifications to denied claims in order to resubmit them to insurance companies for proper reimbursement.
Responsible for handling Electronic claims management for insurance and obtaining accurate reimbursement for healthcare claims by utilizing specialized medical classification software to assign procedures and diagnosis codes for insurance billing
Evaluating claims data to ensure that assigned codes meet required legal and insurance rules and that required signatures and authorizations are in place prior to submission
Submission of eClaim through DHPO with proper justification
Utilizing technical coding principals and guidelines with DHA policies to assign appropriate ICD 10 diagnosis and ICD-10-PCS /CPT-4 procedures for hospital reimbursement
Analyzing In-patient and out-patient bills and synchronizing pre-payment chart abstraction (coding) prior to benefit application/payment and recovery of overpayments related to fraudulent and/or abusive billing and coding practices
Identifying, investigating and correcting fraudulent and/or abusive billing and coding practices
Delivering customer service support and education related to coding, medical record documentation requirements, healthcare compliance and fraud, waste and abuse to vendors and contracted providers/facilities
Assisting the External Audit Manager with developing, implementing and performing compliance related pre-payment auditing and monitoring activities
Checking the proper approval before submission of claims and follow up the approvals with insurance companies
Updating the CPT codes in the system and clarifying the doubts from the billing department
Meeting routine deadlines and work schedules as well as timely and accurate completion of special projects and any other duties as assigned
QA for coding and claims evaluation \[Revenue Cycle Management
Primarily involved in the production and quality deliverables of an ED coding project while routinely managing a coding team of physicians and hospital coding staff handling multi-specialty projects
Reviewed medical records, patient medical history and physical exams, physician orders, progress notes, consultation reports, diagnostic reports, operative and pathology reports, and discharge summaries in order to verify and ensure that:
o The diagnosis codes are supported by the documentation and with ICD-9-CM Guidelines for Coding and Reporting
o The diagnosis codes for each chronic or major medical condition are captured and submitted within the permitted timeframe
o The diagnosis codes unsubstantiated by the record are eliminated
Audited the junior coders work and maintained the team quality as per the coding protocols
Worked on pilot projects, client contacts and documenting the client specifications for the team to follow and ensured that expected deliverables for clients and management are met
Class 12 ►