Mohit Sharma

1. Follow up on denied and partially denied claims.

2. Sending appeal via Availity, UHC Portal and on mailing address and fax.

3. Sending patient letter when COB is not updated or patient is not active on DOS.

• Responsible for credentialing new healthcare providers joining the organization or network
• This involves verifying their education, training, licensure, board certifications, work history, malpractice history, and other credentials required for their specialty
• Manage the re-credentialing process for existing providers on a regular basis to ensure they maintain their qualifications and credentials
• This typically involves reviewing updated documentation and verifying ongoing education and training requirements
• Complete the enrollment process for providers to participate in various insurance plans and networks
• This includes completing and submitting enrollment applications, tracking application status, and ensuring compliance with payer requirements

• Review Denied Claims: The Appeal Specialist is responsible for reviewing denied claims received from insurance companies or other payers
• They carefully analyze the denial reasons provided by payers to understand the basis for the denial
• Research and Documentation: Appeal Specialists conduct thorough research and gather all relevant documentation necessary to support the appeal of denied claims
• This may include medical records, treatment plans, coding documentation, and payer policies
• Prepare Appeals: Based on their review and research, Appeal Specialists prepare detailed and well-documented appeals to challenge the denial of claims
• They ensure that appeals are submitted within the required timeframe specified by payers to avoid forfeiture of appeal rights
• Compose Appeal Letters: Appeal Specialists draft appeal letters that clearly and persuasively articulate the reasons why the denied claim should be overturned
• They provide a thorough explanation of the medical necessity, appropriate coding, and compliance with payer policies
• Coordinate with Providers and Payers: Appeal Specialists collaborate closely with healthcare providers, clinicians, and billing staff to gather additional information and clarify any discrepancies related to denied claims
• They also communicate with payer representatives to understand their review process and address any inquiries or requests for additional information
• Track Appeal Progress: Appeal Specialists monitor the progress of submitted appeals and track their status through the appeals process
• They ensure that appeals are followed up on in a timely manner and escalate unresolved issues as needed to expedite resolution
• Maintain Appeal Records: Appeal Specialists maintain accurate records of all appeals submitted, including documentation of correspondence, appeal letters, and outcomes
• They also track appeal outcomes and analyze trends to identify opportunities for process improvement

• Collect payments for outstanding claims and ensure payments received are reconciled correctly
• Research Denials and submit Appeal
• Maintain knowledge of current contracts with insurance companies for correct payment methods for medical Services like Emergency, Observation, Carveout, Drug Codes, Physical therapy, Lab, Radiology and so on and payment methods we follow different -2 multiplier like 100% of OPPS, 172 relative weight of BCBS, 182% of Aetna, UHC, HOMETOWN and Case Rate payments ETC and for BCBS, MEDICARE and MEDICAID we use updated calculator for correct payments
• Identify and report trends in carrier payments and denials, which includes documentation of actions taken to resolve issues
• Review and take appropriate action against correspondence(including EOBs, Denial Letter) within a timely manner

• I used to follow up denials for example CO-16, CO-22, CO-146, CO-239 and so on
• Research and resolve denied and unpaid claims from various insurance companies using multiple resources such as payer website, requesting telephonic reconsiderations, etc
• Recognize payer claims processing problems and must be able to take the appropriate action to resolve such issues
• Revenue Cycle Management Flow chart- 1
• Appointment 2
• Patient Eligibility Verification 3
• Registration 4
• Medical Transcription 5
• Coding Team 6.Charge Capture 7
• Claim Submission 8
• Payment posting 9
• Account receivable follow up
• I used to work on special projects and I was providing on Job training to new hires about system navigation and process updates
• I used to work as an Acting Quality Analyst where I used to audit accounts of the team members and also discuss process improvement with the Client, (U.S Quality Team) on calibration call