<p>The position will work with clinical and revenue cycle staff to minimize front end denials and maximize overturned denials to ensure appropriate payment is received for services rendered. They will assist revenue cycle metrics to stay at target. Key responsibilities include analyzing denial reasons, identifying trends, and participating in interdepartmental resolution strategies. They will maintain and monitor the integrity of the claim development and submission process as it relates to denial prevention. They will provide oversight of the appeals process and direction regarding appeals and claim disputes. The will collaborate with Utilization Management, Case Management, Coding, and Billing department and insurance companies to resolve denied claims promptly. They will coordinate and facilitate education programs for medical staff, department heads, managers, and staff in regard to proper appeal process.</p> <p>Education/Training:</p> <p>Bachelor's degree in business, healthcare, or related field</p> <p>Licenses/Certification:</p> <ul> <li> <p>CCS</p> </li><li> <p>RN preferred</p> </li></ul> <p>Required Qualifications and Skills:</p> <ul> <li> <p>Minimum of 3 years of experience in healthcare with demonstrated knowledge of hospital billing and reimbursement, Medicare and Medicaid denials and appeals, third-party contracts, federal and state regulations relating to denials and appeals.</p> </li><li> <p>Strong writing and communication skills.</p> </li><li> <p>Working knowledge of claim financial statements and ability to analyze financial information and determine financial impact of possible changes.</p> </li><li> <p>Positive interpersonal communication skills (both oral and written)</p> </li><li> <p>Well organized and possess the ability to prioritize multiple tasks.</p> </li><li> <p>Meticulous and have efficient/effective work habits.</p> </li><li> <p>Able to work independently.</p> </li><li> <p>Proficient in use of Microsoft Word, Excel, and related software.</p> </li></ul> <p>Preferred Qualifications and Skills:</p> <ul> <li> <p>Proven record of decreasing initial denial rates and increasing overturned denial rates via the appeals process.</p> </li><li> <p>Facility coding experience or knowledge of coding in a hospital setting.</p> </li></ul> <p>Essential Job Functions:</p> <ul> <li> <p>Key responsibilities include analyzing denial reasons, identifying trends, and participating in interdepartmental resolution strategies.</p> </li><li> <p>Maintains and monitors integrity of the claim development and submission process as it relates to denial prevention.</p> </li><li> <p>Maintains data on the types of claims denied and root causes of denials and collaborates with appropriate parties to make recommendations for improvements and resolving issues.</p> </li><li> <p>Develops and implements administrative procedures and review of current processes to enhance coding activities related to denials.</p> </li><li> <p>Receives, reviews and monitors progress reports from medical records ancillary and other departments related to denials/appeals and takes the necessary steps to implement positive change.</p> </li><li> <p>Works with departments involved to ensure understanding of Local Medical Review Policies and National Coverage Determination guidelines and the use of Advance Beneficiary Notices</p> </li><li> <p>Integrates financial clinical and coding processes to improve compliance and maximize reimbursement.</p> </li><li> <p>Coordinates and facilitates denial prevention education programs for medical staff, department heads, managers, and staff.</p> </li><li> <p>Provides oversight of the appeals process and direction regarding appeals and claim disputes.</p> </li><li> <p>Collaborate with UM, CM, Coding, and Billing department and insurance companies to resolve denied claims promptly.</p> </li><li> <p>Works to maintain third-party payer relationships including responding to inquiries and other correspondence, coordinating meetings, and setting up arbitration between parties.</p> </li><li> <p>Executes the denial appeals process which includes receiving assessing documenting, tracking, responding to and/or resolving denials with third-party payers in a timely manner in conjunction with applicable internal departments.</p> </li><li> <p>Systematically tracks the status and progress of denials and appeals.</p> </li><li> <p>Conducts relevant research to assist with completing the appeals process and to stay informed on best practices and policy reforms.</p> </li><li> <p>Coordinates and facilitates education programs for medical staff, department heads, managers, and staff with regards to proper appeal process</p> </li><li> <p>Creates internal and external correspondence accurately, clearly, concisely, and professionally while following organizational federal and state regulations.</p> </li></ul> <p>Other duties:</p> <p>Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.</p> <p>AGE AND DIVERSITY RELATED CRITERIA:</p> <p>Consistently treats patients, colleagues and visitors with dignity and respect, while being sensitive to the differing needs of all age groups, backgrounds, characteristics, and cultures.</p> <p>ABILITY TO FULFILL JOB EXPECTATIONS: Must have the ability to perform the essential functions of the position, including required work hours, locations, and physical demands, without posing a direct threat to the health and safety of themselves or other individuals in the workplace, and with or without reasonable accommodation.</p> <p>PHYSICAL DEMANDS:</p> <p>Sit for long periods of time. Repeat the same movements. Use hands to handle, control, or feel objects, tools, or controls. See details of objects that are less than a few feet away. Speak clearly so listeners can understand. Understand the speech of another person. Use fingers to grasp, move, or assemble very small objects.</p> <p>Sturdy Memorial Hospital is an equal employment opportunity employer. There is no discrimination because of race, color, creed, age, gender, sexual orientation, national origin, veteran status or disability.</p>