Danielle Lettman

• Investigate all non-standard claim problems
• Investigate and process adjustment requests
• Adjust claim payments resulting from duplicate payments, incorrect payee, etc.
• Adjudicating claims for different lines of businesses in Epic

· Working in different work queues every day paying claims, adding hold & pend& deny codes, working with CMS and UD claims.

• Respond to questions from claim processors and examiners
• Create new standard operation procedures for new products or procedures.

· Subrogation for MercyCare Insurance department including all correspondence, phone calls, running payment reports and then documenting.

· Started last year running interviews for new hires

· Handle all the scanning and linking documents for MercyCare Insurance department including claims, Coordination of Benefits forms, refunds, Subrogation, any other letter we sent out.

· Keeping track on excel spread sheet on refunds for our department to see if any panders are happening so can be corrected.

· Cover for receptionist duties are phones calls for whole MercyCare building, any walk-ins, sorting mail for whole building and taking payments for premiums & medical bills

· Handle all the grace period claims for our HMO member

· Verifies claims are received by the payer and follows up to obtain payment via phone calls, portal or website use.

· Reviews claim adjustment reason codes or explanations of benefits received by the payer to determine what reasons for denials records are indicating for appropriate follow-up.

· After denial review, evaluates next steps and takes action to call payer, follows up with a resubmission or dispute/appeal/reconsideration as required by payer, or works internally to receive payment on account.

· Drafts an appeal or complete reconsideration forms when applicable based on payer requirements in a format that is logical and relates to the open denial of payment.

· Obtains and sends medical records during the appeals process when needed to substantiate medical necessity.

· Uses computer systems/technology to locate claims information to resolve account balances.

· Reviews accounts based on patient or departmental inquiries. Also, works and follows up with other Mercyhealth departments in a timely fashion if outstanding questions are not resolved and a claim is in jeopardy of not being paid.

· Interacts with other PFS staff members to provide pertinent information and to ask for guidance to resolve knowledge base deficiencies.

· Researches accounts at a higher level that are denied for No Authorization as a priority in the attempt to appeal or escalate to Precertification department if a retro authorization may be needed.

· Works billing functions when needed.

· Escalates high dollar accounts for a second level appeal if needed.