As a Medical Records and Appeals Coordinator at a third-party medical billing company specializing in substance abuse and behavioral health services, you will be responsible for handling medical record requests, managing the appeals process for denied insurance claims, and ensuring the application of medical necessity criteria. This position requires an understanding of ASAM, LOCUS, and DSM criteria to demonstrate the medical necessity of services for clients, as well as the ability to write clear and effective appeal letters. You will work independently to investigate denials, craft comprehensive appeals, and ensure compliance with payer requirements.
You will utilize EMR systems (specifically KIPU and SunWave) to manage and track records, and your attention to detail will be essential in analyzing coding discrepancies and resolving claim issues.
Research and determine the appropriate course of action to appeal denied claims, using a thorough understanding of ASAM, LOCUS, and DSM criteria to demonstrate medical necessity for the requested services.
Prepare well-organized, clear, and compelling appeal letters that include medical records, billing information, and supporting documentation.
Follow up on the status of appeals and escalate unresolved issues to the appropriate internal team members as necessary.
Apply payer-specific medical necessity guidelines to claims and appeal documentation, ensuring all insurance requirements are met.
Process requests for medical records from commercial insurance companies in compliance with HIPAA and applicable laws.
Ensure the timely release of medical records, maintaining a high level of accuracy and confidentiality in handling sensitive patient information.
Maintain detailed documentation of all requests, releases, and responses.
Investigate reasons for denied claims and identify discrepancies or errors by analyzing ICD-10, CPT codes, and billing forms (CMS 1500, HCFA 1500, UB04).
Work independently to resolve claim issues, coordinating with insurance companies to correct errors and resubmit claims where necessary.
Communicate with insurance providers to ensure proper reimbursement for services rendered.
Demonstrate proficiency in medical billing processes, including understanding ICD-10 and CPT coding systems, and applying insurance protocols.
Utilize medical billing software and EMR systems (specifically KIPU and SunWave) to input and track billing information accurately.
Stay informed of changes in billing regulations and apply those updates to claims and appeals.
Work independently to manage medical record requests, resolve denied claims, and complete appeals.
Ensure that all claims and appeal documentation align with payer-specific requirements and meet industry standards.
Previous experience in medical records management, medical billing, or healthcare administration required, preferably in a third-party billing or insurance environment.
In-depth knowledge of ASAM, LOCUS, and DSM criteria for mental health, behavioral health, and substance use disorders.
Strong experience with ICD-10, CPT coding, and billing forms (CMS 1500, HCFA 1500, UB04).
Proficiency in EMR systems, specifically KIPU and SunWave, is required.
Strong ability to write detailed, accurate, and professional appeal letters for denied insurance claims.
Experience with medical necessity guidelines and a strong understanding of insurance policies, denials, and the appeals process.
Excellent organizational skills and ability to work independently with minimal supervision.
Knowledge of HIPAA and patient data protection standards.
Proficiency in Microsoft Office Suite (Word, Excel, Outlook).
Strong communication skills and the ability to engage with insurance companies professionally and effectively.
Ability to prioritize tasks and work efficiently under pressure, meeting deadlines consistently.
Previous experience in a third-party billing company, behavioral health treatment center, or healthcare payer environment.
Knowledge of substance use disorders and mental health treatment.
Experience writing and handling utilization review and insurance authorization documentation.
We have an experienced and highly effective team of billing professionals dedicated to simplifying the complexities of medical billing, enabling healthcare providers to focus on what matters most: delivering exceptional patient care.
