Denials Specialist, Denials

40 hours per week, day shift

JOB SUMMARY: Responsible for the reporting, monitoring, analysis, and follow-up of denials. Identifies whether a denial can be appealed or if a write-off is required. Provides appropriate denial information to root cause areas to ensure systems, processes and measures of effectiveness (e.g. remediation action plans) are created and implemented to reduce/eliminate denials. Performs specialized duties for the team and assists the Assistant Manager and Manger with daily activities. Maintains a thorough knowledge of tasks performed in the department in order to fulfill the task of the other team members in their absence.

EDUCATION/EXPERIENCE: High school diploma or GED required with two years' experience payment variance, denials management, or a healthcare business office environment. College experience or business courses including medical terminology, typing, word processing and knowledge of insurance companies preferred. WFBH experience preferred.

LICENSURE, CERTIFICATION, and/or REGISTRATION: N/A

ESSENTIAL FUNCTIONS:

1. Reviews and researches claims in which a denial of payment has been received from the payer.

2. Identifies the root cause of the denial and addresses the denial issue with the appropriate department (i.e. Billing, CDM, Clinical Documentation, Coding, etc.) Performs extensive follow-up, completes appeals and makes referrals to other stakeholders, when appropriate.

3. Utilizes all appropriate systems to effectively research claims and complete steps to submit information necessary to process or appeal claims. Investigates and ensures that questions and requests for information are responded to in a timely and professional manner to ensure resolution of outstanding claims.

4. Completes follow-up with patients, as necessary, to obtain additional information.

5. Prepares necessary documentation to submit appeals to payers when payment is delayed or denied. Rebills or reprints claims as necessary and appropriate.

6. Completes and requests adjustments to a claim, as appropriate, based on the dollar threshold of the adjustment.

7. Reviews, works and reports all claims that have aged more than the specified grace period stipulated in the policies and / or contracts.

8. Tracks and reports violation of prompt pay / adjudication terms by payers and follows up proactively with payers to provide necessary additional documentation for patient claims that have been reviewed by payers and are awaiting documentation to determine adjudication.

9. Documents patient claims appropriately. Updates the claim with appropriate transactions to reflect current collection status.

10. Reports issues and trends to appropriate PFS management personnel and works collaboratively to develop solutions.

11. Organizes work / resources to accomplish objectives and meet deadlines. Demonstrates problem-solving skills related to denial analysis.

12. Demonstrates the willingness and ability to work collaboratively with other key internal and external staff to obtain necessary information to address denial management issues. Provides direction to members of the team, serves as a resource for questions.

13. Participates in all educational activities, and demonstrates personal responsibility for job performance. Assists in the development of training material. Uses supplies and equipment effectively and efficiently.

14. Maintains compliance with established corporate and departmental policies and procedures.

15. Performs other duties, as requested.

SKILLS/QUALIFICATIONS:

• Excellent phone etiquette and internal/external customer service skills
• Demonstrates knowledge of insurance regulations and policies, payment policies/guidelines and the ability to communicate and work with payers to get claims resolved and paid accurately.
• Microsoft Word and Excel experience
• Demonstrate in-depth knowledge and experience in the following technology solutions: patient accounting, optical imaging and scanning, patient systems and internet-based insurance websites
• Extensive knowledge of Medicare and Medicaid regulations and third party insurance guidelines preferred
• Knowledge of denial management and contract reviews preferred
• Consistently demonstrates a positive and professional attitude at work
• Meets productivity requirements to ensure excellent service is provided to customers

WORK ENVIRONMENT:

• Clean, office environment
• Subject to stressful situations
• Contact may involve dealing with angry or upset people
• Flexible and available to provide staffing assistance for any/all disaster or emergency situations