Reporting to the Denial Management Manager, oversees the denial and appeal processes for all payor types ensuring collaboration in denial management practices, striving to minimize lost revenue. Conducts analysis on denials and appeals and identifies trends that present process improvement and revenue protection opportunities. Oversees the denial management system administration. Monitors state and federal regulatory agencies to maintain up-to-date knowledge on changing rules and regulations affecting denial prevention and management practice.
Essential Job Functions:
1) Oversees all denial/appeal processes utilizing the denial management system to monitor denial account processing. Documents findings and maintains accurate written and system generated records for all denials. Processes appeals for all outpatient denied accounts and monitors all first and second level appeals by the denial team, ensuring that billing and denial filing deadlines are met and payments and/or account adjustments are timely and accurate.
2) Manages the integrity of denial data by auditing denials and correcting data errors. Develops standard and ad-hoc denial management reports, identifying variances and trends. Identifies common areas of errors/problems, such as contract inconsistencies, eligibility, compliance, and system issues; makes recommendations to management for reduction of errors which provides for cleaner claims and resulting in faster turnaround in payment.
3) Maintains current knowledge of Medicare/ Medicare Replacements, Medicaid/ Medicaid Replacements and Managed Care Contract requirements, monitoring Center for Medicare and Medicaid Services (CMS) guidelines and industry changes. Maintains knowledge of federal, state and other regulatory agency rules and regulations.
4) Serves as the liaison to all hospital departments and off-sites facilities for denial prevention and management to facilitate optimal reimbursement. Performs denial root cause analysis and provides feedback and education to all departments and physician's offices outlining opportunities for process improvements to reduce denials. Assists ancillary departments in negotiations with payers on denied claims. Functions as the "hub" of the hospital's denial management, providing assistance to all departments for prevention and recovery of denials.
5) Performs RAC account review, prepares appeals for medically unlikely edits (MUE) rejections and performs account reconciliation for all RAC accounts, posting adjustments and refunding secondary payers as appropriate. Provides feedback to departments for process improvements related to MUE issues as well as other RAC "billing" denials.
6) Performs and maintains adjudication functions and skills including calculating allowances, account adjustments, identification of contract requirements and inconsistencies and correction of account/ insurance errors. Takes on and manages projects related to claims resolution as required.
Minimum Formal Education Required:
1. High School Diploma or equivalent. Associates Degree in Business, Accounting or Healthcare, or Bachelor's Degree preferred.
License and/or Certification Required: N/A
Minimum Length and Nature of Experience Required:
1. Minimum of three years adjudication, reimbursement, denial management, utilization review or equivalent in a healthcare environment required.
2. Knowledge of health care reimbursement models, Medicare, Medicaid and Managed Care federal, state and other regulatory agency rules & regulations required.
3. Experience using Microsoft Office Products required. Experience with Epic required.
4. Experience working with databases, computer based data management and report writing experience preferred.
Special Knowledge and Skills Required:
1. Excellent verbal communication and interpersonal skills needed to work in a collaborative practice setting with an interdisciplinary team and to interact effectively with patients, physicians, payers and other agencies.
2. Excellent critical thinking and analytical skills necessary to identify and resolve issues and independently review, research, analyze and provide feedback regarding processes that affect payment and contracting.
3. The assertiveness and tact necessary to represent the hospital's interests in negotiating payments/ reversals of denials.
4. Familiarity with claims processing, understanding of CPT, HCPCS, DRGs and ICD (9-10) codes.
5. Excellent writing skills necessary to draft appeal letters in a clear, concise, and persuasive manner.
6. Intermediate to advanced computer skills necessary to utilize multiple computer systems and software applications such as Epic, Cobius, AEOS, MS Word, Access, Excel, and the ability to navigate and utilize multiple payer portals and service review websites (system administrator function as required).
7. Organizational skills necessary to work independently and to ensure that all staff follow through on daily activities, multi-task and effectively manage time and resources.
8. The ability to effectively manage workflow through automated processes while being proactive, seeking out process improvements or information to avoid issues and/or reporting issues as soon as identified.
9. Ability to project a professional image.
10. Ability to work a flexible schedule.
11. Openness and Willingness to work collaboratively and respectfully with all others while following through on commitments to internal and external customers, listening patiently without interrupting others, and must maintain a professional and calm demeanor under stressful situations.
12. Openness and willingness to perform all other job duties as assigned.
Physical Demands/Environmental Conditions:
1. Requires very little physical effort. Rarely required to walk or stand for prolonged periods. May require occasional lifting or moving lightweight material, or rarely lifting or moving average weight material.
2. The flow of work and character of duties involves normal mental and visual attention.