The Denials Management Outpatient Appeals Specialist is responsible for analyzing, resolving, monitoring and reporting clinical denial and appeals to Denials Management leadership as appropriate.
The Denials Management Outpatient Appeals Specialist is responsible for appeals and follow-up on clinical denials escalated through a work queue, providing appropriate denial information to be submitted to departments to ensure systems, processes and measures of effectiveness (e.g. Remediation action plans), are created and implemented to resolve root cause issues and reduce/eliminate denials.
RESPONSIBILITIES: The specific responsibilities include, but are not limited to:
- Performs extensive follow-up, completes appeals and referrals to other stakeholders, when appropriate
- Investigates and/or ensures that questions and requests for information are responded to in a timely and professional manner to ensure resolution of outstanding accounts
- Performs ongoing monitoring and follow-up of denials accounts worked as appeals, as necessary, to ensure maximization of collection dollars by providing appropriate follow-up and documenting actions taken
- Manages associated appeals vendors and process ensuring accuracy in account population submission and timely response to follow-up/resolution
- Identifies trends on appeals and accurately adjusts associated accounts while driving actionable resolution and prevention steps
- Utilizes all appropriate systems to effectively research accounts and complete steps to submit information necessary to process or appeals accounts
- Completes follow-up with patients, as necessary, to obtain additional information
- Prepares necessary documentation to submit appeals to payers when payment is denied
- Complete all necessary outgoing calls and answer incoming calls, as appropriate
- Make revisions or changes to insurance information, as appropriate
- Requests the rebilling accounts as necessary
- Complete and/or request adjustments to an account, as appropriate, based on adjustment thresholds
- Reviews, works, and reports (with accuracy) all accounts that have aged more than the specified grace period stipulated in the policies and/or contracts
- Documents in Epic follow-up actions performed and additional follow-up by other areas if applicable on patient accounts
- Meets regularly with stakeholders to provide education and prevention strategy techniques with clinical and operational departments
- Prioritizes work/resources to accomplish objectives and meet deadlines
- Maintains compliance with federal, state, and local regulations and HIPAA
- Maintains the privacy and security of all confidential and protected health information; job duties warrant a “high” level of computer system access (all necessary areas) to patient information ONLY for those job functions as outlined in this job description; uses and discloses only that information which is necessary to perform the function of the job
- Interfaces with other key internal and external staff to obtain necessary information to address payment variance and denials management issues or requests
- Reports issues and trends to appropriate management personnel and works collaboratively to develop solutions and educational deliverables
- Participates in necessary educational activities, and demonstrates personal responsibility for job performance
- Willingness to participate and share expertise on projects, committees , and other activities, as deemed appropriate
- Meets or exceeds expectations for data quality, customer service, payment variance management turn-around and productivity
- Maintains satisfactory attendance record and punctuality record as set forth by HSS
- Consistently demonstrates a positive and professional attitude at work
- Maintains stable performance under pressure
- Responsible for other related duties, as assigned
EDUCATION AND CERTIFICATIONS:
- Bachelors required, RN preferred
- Current State LPN
- Epic Knowledge Preferred
EXPERIENCE AND COMPETENCIES:
- 1-2 years of related experience including customer service etiquette with internal/external customers and at least one year case management experience preferred
- Clinical Skills to include the ability to read and interpret medical records
- Demonstrates proficiency in Microsoft Office applications and others as required
- Demonstrates expert level proficiency in Excel
- Demonstrates knowledge of insurance regulations, payment guidelines and policies and the ability to communicate and work with payors to expeditiously resolve denials and receive full and accurate payment
- Exhibits extensive knowledge of Medicare and Medicaid regulations
- Knowledge of Third Party claim filing, contract reimbursement and other insurance guidelines
- Exceptional interpersonal and influencing skills; success at cultivating strong relationships with internal stakeholders and creating partnerships throughout the organization. Experience working with executive and medical leadership, especially physicians and their offices.
- Well organized and disciplined; can work independently and lead large organizational initiatives and teams through proper engagement and involvement to achieve desired results.
- Resolves issues through innovative problem solving and solution development; capable of gaining commitment to project goals.
- Stays current on healthcare industry trends and reform; can identify potential impacts and/or problems that may arise during conversation and translate them into remedial action plans.
- Outstanding communication skills: succinct and easy to understand, a good listener, skilled at influencing a variety of people. Capable of developing and implementing educational programs for a diverse audience.
- Smart and insightful, mentally tough and resilient. Remains calm in a crisis. Highly confident, results-driven person who is focused on achieving the goals of the organization.
- Unquestionable personal integrity. Exudes credibility and professionalism. Very likeable. Quickly builds confidence in others. Team player and understands his/her role in relationship to others.
- A highly committed individual, with the necessary drive and stamina to successfully oversee the denials and management process.