Specialist, Denials Appeals

Overview

The Denial Appeals Specialist, functions as a hospital liaison with external third-party payers to review denied claims and write appeals for such claims and retrospectively pre-certify Medicaid, Medicare and private insurance accounts. 

Responsibilities

• Responsible for utilization chart reviews.
• Review denials and make determination as to the admission met clinical criteria for inpatient level of care.
• Focuses on the review and analysis of governmental denial rationales and provides appropriate medical necessity appeal services.
• Reviews governmental contractor’s response letter in comparison to the medical records.
• Audits and coordinates completion of patient records required to retrospectively pre-certify accounts and appeal insurance denials.
• Identifies areas for documentation and/or process improvement and promotes pro-active documentation compliance for reimbursement.
• Demonstrates dynamic ability to adapt to ongoing changes within the health insurance industry in order to effect and implement positive changes for the financial growth of One Brooklyn Health (OBH).
• Audits records and communicates with facility regarding missing or insufficient medical documentation.
• Audits medical documentation for adherence to Medicare guidelines relating to inpatient services (or other Medicare issues) and draft appropriate appeal letters based upon professional clinical opinion as to the medical necessity of the services provided.
• Research issues using federal or state law, federal regulations, and relevant OBH policies.
• Identifies underlying root causes for potential denials and develops a plan to reduce number of denials.
• Assures all discussions and appeals are filed timely with Medicare and private insurers.
• Performs other duties as requested.

Qualifications

Education:

• BA/BS in Health Care Management

Experience:

• Minimum 5 years of medicine/clinical and/or denial/appeals management/utilization review experience in a health related setting.

Knowledge and Skills:

• Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem solving skills, ability to set priorities and multi-task
• Ability to communicate with multiple levels in the organization (e.g. managers, physicians, clinical and support staff).
• Ability to maintain a strong relationship with the medical staff and work collaboratively to positively affect clinical and financial outcomes
• Assertive and diplomatic communication, proven ability to function on a multidisciplinary team.
• Excellent organizational skills including effective time management, multi-task, priority setting and process improvement.
• Detail orientated.
• Ability to fully utilize OBH’s electronic record systems, equipment and other healthcare and billing systems relevant to this position.
• Knowledge of databases, ability to learn database systems other than Microsoft Office suite.

Licensure/Certifications:

• None required.

Physical Requirements:

• Position requires prolonged periods of standing, reaching, walking throughout the working day.  Position will be required to stoop, bend, lift, and carry items weighing up to 25 pounds.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The statements herein are intended to describe the general nature and level of work being performed by employees, and are not to be construed as an exhaustive list of responsibilities, duties, and skills required of personnel so classified.  Furthermore, they do not establish a contract for employment and are subject to change at the discretion of The Brookdale Hospital Medical Center.

BHMC is an equal opportunity employer, it is our policy to provide equal opportunity to all employees and applicants for employment without regard to race, color, religiion, national origin, maarital status, military status, age, gender, sexual orientation, disability or handicap or other characteristics protected by applicable federal, state, or local laws.