Claims Appeals Representative

Description

Providence St. Joseph Health is calling a Claims Appeals Representative to work remotely within our footprint states: AK, CA, MT, OR, TX and/or WA.

The Appeal and Grievance Specialist position is responsible for day to day review, coordination and management of technical denials requiring background and understanding from a provider operational and payer logistical perspective. Works closely with the Clinical Denial RN and support staff to review denied accounts, prepare rebuttals, discuss denials with payer representatives and monitor outcomes of follow-up activities. Works closely with the Clinical Denial RN on nuances associated with denials of a clinical nature.

Responsibilities:

• Evaluates all Ministry technical denials for possible overturn opportunity. Works closely with payers both on the phone and through electronic means to resolve denials and receive payment on accounts.
• Works as part of a team to develop and administer all technical denial workflows and processes.
• Reports regularly to the Revenue Cycle Services PFS Manager on technical denial activities, including managing overturn rate data and continually evaluating activities at the ministry for improvement.
• Works closely with Clinical Denial RN to review cases and provide guidance in understanding the interplay between clinical and technical denials.
• Tracks and manages denied accounts, including triaging clinical denials with the Clinical Denial RN to quickly and expeditiously evaluate collectability. Based on initial review of accounts, manages various “buckets” of issues across ministries to resolution.
• Identifies and escalates consistent issues and trends with payers to support RCS leadership in meeting with payers to resolve issues.
• Develops relationships with payer representatives and key Ministry contacts to support the expeditious overturn of denials.
• Provides fact-based information to Ministry Liaisons on a regular basis on technical denial performance with recommendations on process improvements to avoid denials in the future.
• Works with the RCS Leadership to recommend ways to maximize the use of the department to support strategic and operational needs of the Ministries.
• Works with the RCS Leadership to identify training and system gaps and develop strategies to address these gaps.
• Works closely with RCS Leadership to understand contract specifics and provide Contracting with data to support negotiations with payers.
• Recommends technology solutions and improvements to Revenue RCS Leadership to improve efficiencies and minimize delays in appealing rejected claims.
• Works as part of a team to develop dashboards and performance tools for ongoing reporting to Ministries.
• Negotiates, where appropriate, settlements with payers and their counsel on outstanding claims, obtaining proper approvals from RCS Leadership as outlined by policy.

Required qualifications:

• 3 years familiarity with managed care contracting, provider operations and/or payer operations
• 3 years Patient Accounting experience in a physician office, acute hospital, or medical collections
• 3 years Billing collections, or denials management experience and medical terminology
• 3 years experience in medical management computer applications

Preferred qualifications:

• Associate's Degree -or- equivalent educ/experience
• Experience in negotiations
• 1 year experience specifically with Epic applications

Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally and achieving financial security. We take care of you, so you can focus on delivering our Mission of caring for everyone, especially the most vulnerable in our communities.

About Providence

At Providence, our strength lies in Our Promise of “Know me, care for me, ease my way.” Working at our family of organizations means that regardless of your role, we’ll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable.

About the Team

Providence Shared Services is a service line within Providence that provides a variety of functional and system support services for our family of organizations across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. We are focused on supporting our Mission by delivering a robust foundation of services and sharing of specialized expertise.

We are committed to the principle that every workforce member has the right to work in surroundings that are free from all forms of unlawful discrimination and harassment.

We are committed to cultural diversity and equal employment for all individuals. It is our policy to recruit, hire, promote, compensate, transfer, train, retain, terminate, and make all other employment-related decisions without regard to race, color, religious creed (including religious dress and grooming practices), national origin (including certain language use restrictions), ancestry, disability (mental and physical including HIV and AIDS), medical condition (including cancer and genetic characteristics), genetic information, marital status, age, sex (which includes pregnancy, childbirth, breastfeeding and related medical conditions), gender, gender identity, gender expression, sexual orientation, genetic information, and military and veteran status or any other applicable legally protected status. We will also provide reasonable accommodation to known physical or mental limitations of an otherwise qualified caregiver or applicant for employment, unless the accommodation would impose undue hardship on the operation of our business.

We are a community where all people, regardless of differences, are welcome, secure, and valued. We value respect, appreciation, collaboration, diversity, and a shared commitment to serving our communities. We expect that all workforce members in our community will act in ways which reflect a commitment to and accountability for, racial and social justice and equality in the workplace. As such, we will maintain a workplace free of discrimination and harassment based on any applicable legally protected status. We also expect that all workforce members will maintain a positive workplace free from any unacceptable conduct which creates an intimidating, hostile, or offensive work environment.

Requsition ID: 121807

Company: Providence Jobs

Job Category: Claims

Job Function: Revenue Cycle

Schedule: Full time

Shift: Day

Career Track: Admin Support

Department: 4001 SS RC PAYER YIELD NWR1

Address: OR Portland 5251 NE Glisan St

Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.