Denials Management Specialist PRN

PRIMARY JOB RESPONSIBILITIES
Job responsibilities labeled EF capture those duties that are essential functions of the job.

PEOPLE - 20%

1. Trains staff in denials and appeals process, denial management, and medical coverage guidelines. Serves as an educational liaison to clinical, revenue cycle, central business office and facility operational staff, as needed, on payor denials, denial reason and trending, interpretation of payor manuals, medical policies and local/national coverage determinations or other regulatory requirements related to denials and appeals. Contributes to improving department employee satisfaction/engagement. (EF)
2. Assists in mitigating avoidable denials by communicating directly with physicians, case management staff, clinical service areas, department staff, CBO partners, and vendors to convey payor requirements and reasons for denials. Accurately, timely and consistently communicates by telephone, in meetings, email, and other written correspondence in a clear, effective manner, to resolve claim delays or denials. Conducts value-added conversations with the goal to maximize efficiency and avoid denials and write-offs. Feedback should be proactive and continuously cultivated. (EF)
3. Actively participates in payor meetings, including meetings with government reviewers to assist in mitigating denials. Partners with local denial management and/or audit review work groups, impacting them by identifying why services are denied, root causes, and applicable payor medical policies, Local Coverage Determination (LCD)/National Coverage Determination (NCD), etc. to develop successful appeal strategies (EF)

1. Provides clinical support to department staff and management for data gathering and review. Assists in resolution of inpatient and/or outpatient denials, as well as other tasks related to reimbursement or denial mitigation. Participates in regular meetings with Case Management, Revenue Cycle Denial Meetings, department staff meetings, and facility clinical leaders to share information regarding denial trends, audit reviews, and opportunities for reduced denials. Provides Management with feedback on Patient Access Services, Health Information Management, and Utilization Review and other issues, as appropriate, as related to denials. (EF)
2. Proactively monitors Center for Medicare and Medicaid Services (Medicare) (CMS) or other applicable regulatory sources, managed care and payor communications for updates/alerts/releases related to authorization requirements and/or denial management and functions as a support and educational resource to appeal staff, clinical operations, and management. (EF)
3. Partners with management to create applicable tools, resources, letter templates, etc., to support appeal staff to include reviewing letters for appropriateness of appeal position and clinical accuracy. Provides recommendations and assists in resolving payor issues related to reimbursement at risk and the development of strategies to avoid denials. (EF)

1. Analyzes data from various sources (medical records, claims data, Utilization Review Management (UM) criteria such as InterQual or Milliman, payor medical policies, regulatory requirements, etc.); determines causes for denials of payment and partners with management to implement strategies to prevent future denials. Integrates the payor medical policies, case specific medical documentation, regulatory requirements, and claims information into a concise appeal letter or strategy, including appropriate medical records submission as needed. Partners with IT and Billing Managers to review software updates to ensure accurate medical necessity data and compliance with government updates which includes participating in the testing phases to ensure claims are evaluated for medical necessity appropriately. (EF)
2. Responsible for gathering and maintaining accurate statistics on denials, payment recovery, and changes in payor requirements. Provides information to management and senior leadership as needed. Provides timely reports of results of medical necessity denial analysis and reviews to manager as well as key customers at the local entity. (EF)
3. Performs timely review of medical records and remittances for denials to determine root cause and appropriateness. Assists in the development of corrective action plans in the local denial work group which may include partnering with physicians, clinical service areas, patient access, medical records, other operational leaders, etc. (EF)

1. Partners with department leadership, patient access leadership, Case Management, Health Information Management, and facility clinical operations to reduce denials. Reviews denials and/or inquiries referred from other departments and assists in identifying root causes such as medical necessity, contractual, investigational/experimental, plan exclusions, level of care discrepancy, under payments, exhaustion of benefits, and helps determine feasibility of appeal success along with best appeal strategy. (EF)
2. Works with department management and appeal staff to ensure denial trending data is accurate and that all metrics are reported appropriately including specific Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS), denial reasons, trended Diagnosis Related Group (DRG) recoupments, and appeals. Monitors recovery of payments, monitors trends to identify corrective measures needed to prevent denials. (EF)
3. Negotiates, as needed, with payors for a lower level of care for days of service not meeting higher level of care criteria where supported by Case Management and where payor contracts allow. (EF)
4. Analyzes denials to identify process or workflow improvements and partners with management to implement as needed including providing feedback to patient access services and coding staff, physicians, and operational and facility leaders. Identifies internal system activities that may be causing denials and works with stake holders to mitigate avoidable denials. (EF)

1. Collaborates with third party appeal vendors to identify denial and recovery trends and partners with department management to strategically improve processes. (EF)
2. Identifies and assumes responsibility of own learning needs, consults with healthcare team experts and seeks continuing education opportunities to meet those needs. Completes and updates the individual development plan (IDP) on an on-going basis. Ensures own career discussions occur with appropriate management. (EF)

EDUCATION REQUIREMENTS

• Graduate of education program approved by the credentialing body for the required credential(s) indicated below in the Certifications, Licenses and Registrations section.
• Bachelor of Science preferred

• Seven years clinical nursing/patient care experience with five years in utilization review with clinical decision tools such as Interqual, Millimann, etc, case management or equivalent revenue cycle clinical role, including past experience in initiating and facilitating physician peer to peer review, medical/clinical denials and appeals
• Must have experience with prior authorization process for all providers, ordering and rendering.