Description

GENERAL DESCRIPTION:

The Prior Authorization/Denial Specialist is expected to demonstrate an attitude of teamwork by creating a relationship with patient accounts, health information services, finance, clinical managers as well as administration.The position should maintain a constancy of purpose and continuous education of payer billing compliance and reimbursement regulations, especially for Indiana Medicaid, Clinic Option and Medicaid Rehabilitation Option.

DUTIES AND RESPONSIBILITIES:

Responsibilities include daily and/or weekly review of payer denials. This requires logging all denial reasons, patient name, account number, program, service activity code and clinician. In addition, a constant review of government and payer bulletins and memorandums that are specific to billing and coding changes specific to behavioral health and addictions is required.

DIRECT DUTIES:

• Constant review of all remittance advice and explanation of benefits for zero pays and denials. 
• Log all denials by reason code.
• Address denial issues with management.
• Monitor billing and medical policy notices from all payers. 
• Solicit assistance from clinical, health information and/or quality personnel to resolve denial issues. 
• Process and submit appeals when appropriate to all payers. 
• Ensure compliance with federal and state rules and regulations.
• Provide education to clinicians, business office staff regarding Medicare, Medicaid and commercial reasons for denials.
• Cross training to serve as a back up in the finance department when needed.
•  Promotes effective working relationship and work effectively as part of the department team to facilitate departmental goals and objectives.
•  Performs other duties as assigned.

ADMINISTRATIVE:

• Maintain clinical and management records in accordance with assigned Services Programs.
• Maintain 100% UM/UR compliance. 
• Other responsibilities and tasks as may from time to time be assigned.

GENERAL

• Conduct all professional activity in an ethical manner.
• Conform to all applicable policies and procedures.
• In conjunction with other staff assist in identifying and eliminating any situation which jeopardizes the health and/or safety of clients, staff, or others who come in contact with community mental health center operations.
• Utilize literature, workshops and other training aids to continually improve clinical and administrative skills.
• In conjunction with supervisor, complete and implement Individual Professional Development Plan.
• Assist in assuring Edgewater Health compliance with all related licensing and accreditation requirements.

SUPERVISED BY:

Accounts Receivable Director

WORKERS SUPERVISED:

None

Qualifications

MINIMUM QUALIFICATIONS:

• Education – Associate degree from an accredited college or university preferred. Completion of formal bookkeeping or accounting course work preferred.
• Other – Experience with Medicare, Medicaid and Commercial insurance billing required.
• Have knowledge of the healthcare industry specific to Center for Medicare and Medicaid Services (CMS) rules and regulations for behavioral health and addictions.
• Prefer coding experience but not required.