Sidra - Doha, Qatar
Sidra Medicine is a state of the art academic medical center that will function to the level of the highest international standards. Its clinical focus is on the specialty care of women and children. Sidra’s Vision is: “Sidra Medicine will be a beacon of learning, discovery and exceptional care, ranked among the top medical centers in the world”. Achieving this vision will encompass three essential activities: World Class: Patient and Family Centered Care Health Education Biomedical Discovery The Finance department will contribute to realization of Sidra’s vision by providing strategic direction, stewardship and excellence of service. Finance includes the following core functional areas: Financial Services Reporting, Planning and Budgeting Corporate and Treasury Finance Patient revenue, billing and insurance Finance provides services to departments across the organization and also works with external partners at both the operational and government level. The Denials Auditor is a member of the Patient Financial Services Team. The incumbent will utilize clinical skills to provide support with medical necessity reviews in Denials Management; audits patient records to evaluate medical necessity and charge capture in an effort to minimize hospital losses; conducts requested audits to ensure consistency between medical records documentation and billing statements on patient accounts; submits appeals to payers on patient account denials when appropriate; completes comprehensive reviews of clinical documentation and existing coding to determine if an appeal is warranted and provide coding guideline reference material to support the appeal. Performs claim reviews, appeal assessments, charge corrections, and or other account activities which require clinical review or expertise. Reviews medical records to determine the appropriateness and medical necessity of services. Conducts reviews and responds to insurance denials. Writes concise, factual letters and provides medical record documentation to support appeal. Effectively communicates with external and internal stakeholders to ensure argument for appeal is clearly presented. Utilizes pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments. Prepares convincing appeal arguments, using pre-existing payer criteria sets and/or clinical evidence. Demonstrates awareness of payer specific reimbursement methodologies and payer specific policies and procedures regarding charging, coding, billing, claim processing, and dispute resolution. Utilizes clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied. Identifies risk factors, comorbidities and adverse events to determine if payer denial was justified and an appeal is required. Maintains timely denial tracking to ensure an accurate denial log of all cases. Performs duties in accordance with the ethical and legal compliance standards as set by hospital policies and procedures, and all regulatory agencies. Prioritizes and organizes own work to meet appeals and grievance deadlines. Responsible for the denials process, including subsequent appeal to health insurance. Works collaboratively and cross-functionally with other departments to facilitate appropriate resolutions. Work closely with other team members to complete departmental tasks to meet deadlines and accomplish department objectives. Documents completely and accurately within an electronic clinical record. Treats colleagues, patients, and visitors with dignity and respect at all times and promotes and maintains effective communication and teamwork. Maintains confidentiality at all times. Maintains a professional demeanor and upholds the organizational values at all times. Follows all Hospital related policies and procedures. Participates in professional development activities when applicable. Performs other related duties as assigned. Adheres to Sidra’s standards as they appear in the Code of Conduct and Conflict of Interest policies Adheres to and promotes Sidra’s Values In view of the evolving needs and opportunities within Sidra, this position may be required to perform other duties as assigned and reporting relationships may vary. ESSENTIAL PREFERRED Education Bachelors Degree of science in Nursing Experience 3+ years of work experience in hospital insurance billing, utilization review or care management, third party claim audits, or compliance and auditing in a healthcare setting, required At least five (5) years of work experience in hospital insurance billing, utilization review or care management, third party claim audits, or compliance and auditing in a healthcare setting, preferred Working experience with Cerner Patient Accounting System Regional experience working with health insurance providers in the GCC or MENA regions. Certification and Licensure Valid Nursing License with extensive experience in hospital setting. Medical billing certificate or other Revenue Cycle Certificate Professional Membership Job Specific Skills and Abilities Experience with hospital insurance billing and medical necessity criteria for various payers Experience with electronic medical records (Preferably Cerner) Working knowledge of medical terminology, ICD10, HCPCS, CPT codes and revenue codes for billing. Detail oriented with extensive experience in coding medical documentation. Knowledge of computer accounting systems, spreadsheets and applications Excellent written and verbal communication skills Ability to evaluate and use various accounting systems and work independently Proficiency with Microsoft Office suite Fluency in written and spoken English Experience in coding medical documentation is preferred Working with Cerner Patient Billing Application Knowledge of CPT, ICD-10-AM, ACHI Coding and medical terminologies Fluency in written and spoken Arabic is preferred Trust: Being competent; acting consistently, reliably and predictably; acting with honesty and integrity; respecting patient, employee and commercial confidentiality; delivering on commitments Care: Acting with empathy, kindness and compassion; being humble; listening and responding; acting with cultural sensitivity; Caring for patients and staff Teamwork: Sharing information and knowledge and learning from demonstrated expertise; being respectful, and thereby earning respect of others; acting with professionalism; leading and following; collaborating and being accessible Transparency: Frequent and honest communication; open access to information for decision making; willingly acknowledge shortcomings; speaking up about concerns; publishing performance indicators Innovation: Freedom to innovate; welcoming ideas and encouraging creativity; supporting talent; creating confidence; celebrating successes Efficiency: Providing measurable value; using data to drive decision making; having and achieving clear goals; building processes that work; continuously improving outcomes in patient and family care
sidra.org - 3 hours ago - 3 years of experience
