Revenue Adjudication Officer
Cleveland Clinic Abu Dhabi
Total years of experience :15 years, 8 Months
- Accurate assignment of diagnosis(ICD-10-CM code), procedure codes (CPT codes) & appropriate
- Evaluation & Management code following established coding guidelines and abstracting appropriate data for reporting Outpatient, Emergency Room, In-patient, Day case and ancillary services accounts.
- Process, adjudicate, audit and report the claim in accordance with the adjudication rules and standards adhering to expected daily targets, quality, error rate, TAT and other key performance indicators (KPIs)
- Reviews, develops implements, evaluates, and revises charge guidelines for outpatient services to optimize revenue management; effectively implements recommendations and monitors results.
- Ensures that all additions, changes and deletions to charges are consistent with proper charging, billing, coding and pricing practices.
- Understands the process flow of all assigned departments charging processes and monitors and reports charge volumes and late charges.
- Conducts quarterly audits of assigned clinical areas to ensure compliance with charge capture polices and processes.
- Responsible for ensuring that all billable charges are reconciled with coding determinations in an appropriate manner via charge review/reconciliation work flows.
- Responsible for making charge capture related decisions that may require root cause analysis and investigation.
- Assists Revenue Integrity Manager with the development and maintenance of policies and procedures for charge capture and charge reconciliation.
- Identifies system and/or operational problems and participates in the development of solutions for improving charging functions.
- Researches and resolves all charge error reports, working closely with clinical departments to provide education on appropriate charging methods.
- Reviews daily or prior day’s registrations for charge discrepancies. - Remains current with updated coding and billing regulations through continuing education.
- Escalates to Revenue Integrity Manager negative charge trends and recommends solutions for resolving negative trends.
- Updates charge information within Patient Accounting System based on HIM coding results or appropriate clinical documentation.
- Maintains confidentiality of the patient’s confidential health information (CHI) in both electronic and paper formats
- Process, adjudicate, audit and report the claim in accordance with the adjudication rules and standards adhering to expected daily targets, quality, error rate, TAT and other key performance indicators (KPIs)
- Evaluate the medical necessity and consistency of diagnosis, procedure and drug codes and descriptions stated on the claims according to accepted medical coding rules and guidelines
- Ensure accurate application of contractual prices and discounts (if available), schedule of benefits, correct allocation of benefits, collection of deductibles, co-payments, observance of policy limits, and adherence to claims submission protocols
- Understand and work with mandated code sets like ICD codes for diagnosis, CPT codes for procedures, IRDRG codes, HCPCS, Drug Codes during adjudication and processing
- Effectively liaise with and attend to provider, member or other departments’ queries and appeals (answering phone calls, replying to emails etc.) and required information in a timely and professional manner, according to the established guidelines and KPIs
- Contribute in developing, updating and implementing guidelines for evaluation and processing of medical claims according to set policies, procedures and guidelines
- Contribute in developing fraud prevention initiatives and international guidelines
- Support the team in dealing with complex medical related enquiries, reviewing medical reports and selecting suitable medical providers and conducting occasional follow up calls with the medical providers to check deviations in the scheduled treatments
- Participate in special projects, preparation of reports and presentations
- Ensure that business decisions and processes are documented in a professional way
- Deliver high quality customer service and respect medical and work ethics at all time
-Enters claims data into system while interpreting coding and understanding medical terminology in relation to diagnoses and procedures.
-Review and validate the information on all medical claims received and ensure that there is no missing or incomplete information.
-Processes claim forms, adjudicates for allocation of deductibles, co-pays, co-insurance maximums and provider reimbursements.
-Follows adjudication policies and procedures to ensure proper payment of claims.
- Implementing Quality Assurance in the division and initiating investigations.
- General Supervision over the professional care given in the division.
- Liaising with nursing and paramedical staff concerning patient care and observation.
- Responsible for diagnosis and treatment of medical diseases and conditions in accordance with
the health authority - insurance healthcare (ICD9, CPT code and DRG)rules and regulations.
- Provide and directly involve in patient care and promote good health.
- Diagnose, prescribe and administer treatment from common health problems, illnesses and injuries.
- Liaising with other medical and non-medical staff in the hospital to ensure quality treatment
- Monitor and providing general care to patients on hospital wards and in outpatient clinics;
- Admitting patients requiring special care, investigations and treatment;
- Examining and talking to patients to diagnose their medical conditions;
- Carrying out specific procedures, e.g. performing operations and specialist investigations;
- Working with other doctors as part of a team, either in the same department, or within the specialties;
- Liaising with other medical and non-medical staff in the hospital to ensure quality treatment.