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Years of Experience
ProfileAssociate Attorney The candidate will represent healthcare providers in the defense of third party payer audits. Will provide defense of health care entities at all stages of the administrative appeals process. Assist hospitals in resolving denied and underpaid facility claims. Properly handle compliance matters between the providers and insurance companies. Draft complex and contractual appeals and letters to insurance companies. Review and apply client contract language and rates as necessary to resolve denied claims. Utilize payer provider and administrative manuals to dispute denied claims. Ensure that assigned cases are appealed timely. Make proper notations on assigned cases. Maintain worklist through daily audits and the open task report. Ensure that all assigned cases have a follow up and that there are no duplicate follow ups. Address all follow ups promptly. Hand any RUSH cases directly to the responsible party for review. Appeals or submissions are due within two weeks from the date the due date was verified. Indicate the referred amount of all first level administrative appeals filed through the daily worklist. Email and/or call provider representatives to resolve complex claim and appeal issues. Assist with the training of employees and provide necessary feedback as requested by management. Assist recovery staff in pursuing appeals, including the development of new and innovative legal and procedural arguments and tools. Complete initial reviews as assigned. Communicate all employee issues or potential areas of concern to department supervisor immediately. Identify whether a claim has been under or over paid based on the provider's expected reimbursement. Determine if underpayments are based on patient responsibility. Maintain an understanding of Maryland Health Services Cost Review Commission (HSCRC) payment rules. Maintain an understanding of DRG, per diem, case rates and other relevant insurance reimbursement schematics. Apply provider specific reimbursement methodologies, payment policies and provider contracts to each payment reviewed to confirm payment in full. Maintain an understanding of Electronic Remittance Summary Meet all weekly performance standards and goals set by management. Administrative duties or projects as assigned by a Partner or other member of management. Follow all HIPAA guidelines in accordance with the Fotheringill & Wade, LLC Policy, Procedure, and Security Manual. Maintain expert understanding of Medicare and Medicare Advantage regulations regarding payment, coverage, conditions of participation, and other relevant topics. Represent clients during Administrative Law Judge hearings and attend administrative hearings for claim denials by Maryland Medicaid. Law degree from an accredited college or university with 1-2 years of related work experience and/or training.