REQUIRED QUALIFICATIONS

• Two (2)+ years in previous patient accounting or billing experience.
• High School graduate or GED equivalent.
• Understanding of CPT, ICD-10, and HCPCS coding concepts. A CPC or specialty coding certification is required within 12 months of date of hire.
• CPFSS certification within the first 6 months of hire.
• The ability to understand and interpret payer policies and navigate payer websites.
• The ability to use the information to effectively develop an appeal that will result in the denial being overturned and receipt of accurate reimbursement. Follows the requirements for different appeal levels and uses the appropriate forms and method of appeal submission.
• An understanding of payer reimbursement methodologies and guidelines such as OPPS, IPPS, NCCI edits, etc.
• Ability to navigate provider documentation, test results, medication administration records, provider orders, etc. to accurately support the appeal process.
• An understanding of the requirements for a clean claim, including field requirements, for both the professional (CMS-1500) and the facility (UB-1450) claim types.
• Understand the remittance advice, remark codes, reason codes, and other payment information as it relates claims which have a denial posted.
• Knowledge of revenue cycle workflows and systems used within the Revenue Cycle such as Cerner, Trisus, Forvis, Quadax, KaiNexus, 3M, Experian, etc.
• Ability to compile, analyze and effectively present data and complex information in an informative and meaningful way to a variety of audiences, including leadership.
• Ability to effectively present/educate departments within the Revenue Cycle.
• Ability to manage complex issues and manage multiple tasks/projects. Excellent organizational and time management skills; detail oriented and follow through. Self-directed.
• Strong problem-solving, research and analytical skills.
• Positive service-oriented interpersonal and communication (written and verbal) skills required. Ability to effectively present and interact with all levels of the organization, including senior leadership.

PREFERRED QUALIFICATIONS

• Denial Management experience
• College degree in a health-related field
• Payment posting experience

PURPOSE OF THIS POSITION

The purpose of the Denials Management Specialist is to review the initial denial notifications for claims that have been received by the insurance but have been partially or fully denied for reimbursement from the provider. The specialist is expected to identify the root cause of the denial in a timely fashion and appropriately respond to the denial with a response that will result in reimbursement for the covered services that have been provided and prevent any subsequent denials. The specialist will work with multiple departments, including but not limited to, patient access, provider clinics, clinical departments, managed care, billing, coding, and compliance to resolve any outstanding issues which is preventing payments for covered services. The denials management specialist will assist in identifying denials trends, research payer policies, understand coding guidelines, and provide assistance in finding resolution to prevent identified denial trends.

JOB DUTIES/RESPONSIBILITIES

• Duty 1: Handles the end-to-end denial and appeal process, including the receiving, analyzing, tracking, managing, and/or resolving appeal with third-party payers in a timely manner. This includes the initial denial and any subsequent denial that comes from an unsuccessful appeal.
• Duty 2 Carries out appropriate research and analysis to help with the appeals process and stay informed of best practices and policy changes.
• Duty 3: Conducts clear, concise, and professional correspondence with payers and other stakeholders in accordance with organizational processes and expectations.
• Duty 4: Promotes interdepartmental coordination for finding a solution and offers suggestions for improvements.
• Duty 5: Examines payer remittance advice and determines the cause of loss of reimbursement in line with payer criteria.
• Duty 6: Accurately reviews clinical documentation to submit with the appeal that supports the requirements for payment but does not exceed the information necessary for a successful appeal.
• Duty 7: Utilizes payer websites research denials, submits information electronically, and follow up on appeals to expedite the payment process.
• Duty 8: Posts adjustments to claim balances that fall below the low balance threshold as outlined in the Denials Write-Off Approval Policy.
• Duty 9: Relays accurate information to support the appropriate party for A/R reduction and patient satisfaction.
• Duty 10: Identifies trends in denials, works to determine the root cause and successful solutions, shares findings with other members of the team to promote systemness in addressing denials.
• Duty 11: Participates in daily huddles, idea board meetings, staff meetings, and meeting with external departments for managing daily improvements.
• Duty 12: Communicates in a professional manner with patients, representatives from third party payor organizations, provider relations, contract management, other internal customers, and co-workers, etc. in a manner to achieve revenue cycle department AR goals.
• Duty 13: Identifies opportunities for system and process improvement and submit to management.
• Duty 14: Ensures that services are provided in accordance with state and federal regulations, organization policy, and compliance requirements.