Denials Appeals Specialis - #309607

This role will be responsible for monitoring denials, appeals, and resolutions from participating insurance carriers and working proactively to collect from insurance carriers. The incumbent will manage the current appeals process. The specialist will review all referred accounts to determine categorization, level of appeal, and process steps. He/she will provide oversight/assistance for initiating appeals, and personally handle complex appeal responses. The Denial Specialist will work closely with other CRH RCM team members.

These duties and responsibilities described below represent the general tasks performed on a daily basis. Any other duties as needed to drive to the vision fulfill the mission and abide by the values of the organization.

• Researches and analyzes denial data and coordinate denial recovery responsibilities.
• Maintains patient confidentiality and follows HIPAA guidelines
• Follow denials worklist prioritization of invoices established by department policies and procedures with resolution.
• Follow-up with patients to obtain additional information if applicable.
• Researches, responds, and documents insurer and patient correspondence/inquiry notes regarding coverage, benefits, and reimbursement on patient invoices.
• Generate an appeal or reconsiderations based on the dispute reason and contract terms specific to the payer.
• Identifies, analyzes, validates and researches frequent root causes of denials and develops corrective action plans for resolution of denials. Performs retro reviews of denials, submits formal appeal letters and aggressively follows up with the payer in order to achieve optimal financial outcomes. Escalates exhausted efforts for resolution.
• Communicate all denial trends to direct supervisor/manager in order to positively affect the volume of denials and recovery of revenue to CRH.
• Works with the payors to understand specific reasons for denials and preventable measures available to prohibit future denials.
• Analyzes payer contracts (Commercial and Government) in conjunction with underpayments variance report and Contracting systems.
• Responsible for maintaining or managing time effectively to complete assignments within established time frames, optimize collections, and meet performance goals.
• Demonstrates knowledge of all equipment and systems/technology necessary to complete duties and responsibilities.
• Timely and appropriate response to phone calls, internal questions, and correspondence from various departments, outside agencies, and payers regarding information pertaining the resolution of denied claims.
• Organizes job functions and work assignments to effectively complete assignments within established time frames.
• Researches denials included in EOBs for resolution and files appropriately.
• Reviews Contracts for appropriateness in payment, adjustments and contractuals to match the contract guidelines.
• Works collaboratively with physician offices, Patient Access, Utilization Review, HIM and facility clinicians to correct deficiencies in a timely manner.
• Meet and maintain established departmental performance metrics for production and quality.
• Performs other duties as assigned.
  
  

Reports to: Manager or Director

Supervises: None

Responsibilities: None

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

Minimum Required Education: High School Graduate minimum education requirement (any additional education a plus).

Preferred Education: Bachelor’s Degree

Experience

• 3+ years in an Acute Hospital environment
• Must have 3+ years of healthcare related experience consisting of 3rd party billing & collections.
• Must have 2+ years of healthcare denials management, and technical appeals.
• Underpayments experience preferred
• Knowledge of Medicare, Medicaid, and other contract payers (HMO, PPO) preferred
• Healthcare (preferably hospital) oriented experience.
• Must be familiar with payer regulatory policies, medical terminology, and payment and adjustment calculations.
• Work collaboratively with physician offices, Patient Access, Utilization Review, HIM and facility clinicians to correct deficiencies in a timely manner.
• Must be able to adapt to competitive ever changing work environment.
• Strong verbal and written communication skills.
• Should be proficient in Microsoft Office, with heavy exposure to patient accounting software and applications.
• Demonstration of conflict resolution and mediation skills.
• Decision making, problem solving skills, critical thinking and listening skills required
• Solid overall computer skills (MS Office - Word, Excel, Outlook, PowerPoint).
• CPAR (Certified Patient Account Representative) and/or CPFC (Certified Patient Financial Counselor) preferred for positions in clinic/hospital setting within two years of hire.