Delta Health offers health care professionals and people from all walks of life an opportunity to find fulfillment in their jobs as part of a close-knit team. We pride ourselves on our positive work culture. Our team members understand our fundamental commitment to the community and rally around the motto “Excellence, Every Patient, Every Time.” When you embark on a journey with us, you’ll take pride in your work and the impact you have, while building a career with focus and purpose.

Responsible for reviewing all hospital post-billed denials for medical necessity and appealing them based upon clinical expertise and clinical judgment within the Hospital revenue operations. Serves as part of a team of clinical payment resolution colleagues responsible for identifying and determining root causes of clinical denials. Responsible for leveraging clinical knowledge and standard procedures to track appeals through first, second, and subsequent levels, and ensuring timely filing of appeals as required by payers, in addition to promoting departmental awareness of clinical best practices.

• Coordinates denial management processes focusing upon retrospective follow-up and appeal processing with the objective of appropriately maximizing reimbursement based upon services delivered and ensuring that the claim is paid/settled in the timeliest manner possible.
• Performs advanced level work related to clinical validation, coding validation, and medical necessity denial management to manage claim denials in the inpatient and outpatient setting.
• Conducts comprehensive reviews of the claim denial and medical record to make the determination for a written appeal or if a revised claim needs to be submitted.
• Writes and submits detailed and customized appeals to payers based on medical record review and in accordance with Medicare, Medicaid, Medicare-Managed, and Commercial guidelines.
• Submits timely, appeals and monitors and tracked through final outcome; actively manage, maintain, and communicate denial / appeal activity to report suspected or emerging trends related to payer denials to Revenue Cycle management.
• Stay current and compliant with annual updates in MS-DRG relative weights and length of stay, APR-DRG SOI/ROM, LCDs and NCDs for medical necessity, NCCI edits and modifiers, Official Coding Guidelines, condition codes, units reported, and the Revenue Cycle process of State and Federal regulations for facility charges and reimbursement in both the inpatient and outpatient setting.
• Supports Revenue Cycle Director with communication and follow-up processes related to rejections, denials and appeals, ensuring that such activities are tracked, trended and reported back to the denials team.
• Provides detailed understanding or aptitude for resolving denials based on patient status, length of stay, level of care, missing pre-certification, or other clinical reasons and constructing warranted appeals for defined populations as directed by the Supervisor.
• Reviews and understands utilization review and coverage guidelines for multiple payers; Identifies solutions to issues affecting reimbursement as it relates to denial prevention (prospective and concurrent) and provides summary of findings to Supervisor.
• Supports the maintenance of a denial management data base, standard report sets, letter template and other key job aids.
• May provide clinical input to staff in order to facilitate authorization approvals; Assists in marketing efforts and the education of physicians and staff.
• Maintains a strong working relationship in order to ensure proper identification, resolution, and coordination of clinical denials in alignment with payer environment and expected reimbursement.
• Serve as a resource to provide guidance and mentorship in achieving positive operational outcomes.
• Keeps abreast of denial trends and in regulations concerning healthcare financing and payer relations through journals and professional continued education programs, seminars, and workshops.
• Other duties as needed and assigned by supervisor.

• Must possess a demonstrated knowledge of denial management functions.
• Knowledge of and experience in health care including government payers, applicable federal and state regulations, healthcare financing and managed care.
• Knowledge of and experience in case management and utilization management.
• Knowledge of insurance and governmental programs, regulations and billing processes (e.g., Medicare, Medicaid, Social Security Disability, Champus, Supplemental Security Income Disability, etc.), managed care contracts and coordination of benefits is required.
• Customer service background is required.
• Ability to interact effectively with multidisciplinary teams, including physicians and other clinical professionals internally and externally.
• Must have a detailed understanding or aptitude to learn and understand denials resolution based on patient status, length of stay, level of care, missing pre-certification, or other clinical reasons; in-depth familiarity with third party billing requirements and regulations, and writing appeals.
• Thorough knowledge of DRG assignments, ICD-10 codes and regulatory coding guidelines.
• Able to leverage understanding of managed care contracts, and payer behaviors.
• Candidate has a firm understanding of the expected reimbursement on their assigned payers.
• Knows how to read an RA.
• Proficiency is Microsoft Office Products.
• Knowledge of UB-04 and CMS 1500 forms.
• Knowledge in Medical Records and the Appeals process.
• Strong organization skills.
• HIPAA and related Privacy and Security Acts and Regulations.

Why Delta County - Click Here

Delta Health is a county-wide healthcare system that has been serving the Western Slope for over 100 years. We have grown to a 49-bed hospital with locations throughout Delta County. We proudly provide a wide range of medical services that meet the diverse needs of our community members. At all stages of life, we are here to provide remarkable care in a healing environment.

Open Benefits Summary

Employee Benefits: Medical, RX, Dental, Vision, Retirement, PTO, and Scholarships towards continued education.

Medical: Low monthly premiums; 100% coverage for all services provided within our Delta Health System without a deductible or co-payment. We offer alternative coverage to include massage, acupuncture, and chiropractic care. Employer paid Life and Disability coverage.

Paid Time Off: 4 plus weeks of vacation (CAL) a year for Full-Time employees including sick pay and personal time off.

Retirement: 403B Plan -Up to a 3% retirement match.