Under the general supervision of the System Director of Case Management, provides ongoing review of denial appeals as appropriate for concurrent and retrospective authorization and denial claim activities for inpatient and observation accounts. This position will also provide support to access staff and management.
The Denial Management Coordinator will be responsible for the review of denials to determine patterns in errors, payors, and internal processes to improve denial rates and current appeal processes as it relates to ARH. The coordinator will review all referred accounts to determine categorization, level of appeal, and process steps. The incumbent will provide assistance to the nurses initiating the appeals, maintain logs, analyze data, and assist as needed with appeal cases. The position will provide monthly updates to the System Director of Case Management on the current status of appealed claims. Works collaboratively with staff internal and external to the organization.
Special Instructions Under the general supervision of the System Director of Case Management, provides ongoing review of denial appeals as appropriate for concurrent and retrospective authorization and denial claim activities for inpatient and observation accounts. This position will also provide support to access staff and management. The Denial Management Coordinator will be responsible for the review of denials to determine patterns in errors, payors, and internal processes to improve denial rates and current appeal processes as it relates to ARH. The coordinator will review all referred accounts to determine categorization, level of appeal, and process steps. The incumbent will provide assistance to the nurses initiating the appeals, maintain logs, analyze data, and assist as needed with appeal cases. The position will provide monthly updates to the System Director of Case Management on the current status of appealed claims. Works collaboratively with staff internal and external to the organization. Responsibilities Maintains a working knowledge of the requirements of 3rd party payors and communicates changes of these requirements to the Case Managers/UR Reviewers.Reviews denials from 3rd party payors obtained from correspondenceAnalyzes and logs denials by payor for denial reason items and identifies patterns of common denial errors, types, and recurring issues.Facilitates and coordinates denial appeals with internal and external customers in a proactive manner to bring satisfactory resolution.Relays denial information to appropriate billing clerks and management.Utilizes appropriate data, tools, and resources to identify denial patterns and trends.Maintains a working relationship with the Physician Advisor 3rd party vendor.Maintains a working knowledge of programs necessary for denial management (ie: excel, word, insurance portals, EMR)Maintains a working relationship with Finance and Corporate Compliance with regard to denial activity.Maintains up to date knowledge on regulatory agency guidelines as it pertains to area of practice.Maintain work standards that are in compliance with ARH’s policies and governmental regulations and various regulatory agency requirements.Consistently maintains a professional commitment to institutions and department’s goals and objectives. Demonstrates flexibility to the department’s needs and any other internal and external demands on the department. Continually shows commitment to the department by extending one’s self when the need arises.Attends and/or completes all required training programs and can describe his or her responsibilities related to general safety, department/service safety, and specific job related hazards.Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment. QualificationsMinimum Education
High school degree with previous experience in the area of utilization review and case management preferred.
Working knowledge of federal, state, and regulatory requirements in quality assessment, case management, resource management, hospital systems, accreditation, and licensure strongly preferred.
Minimum Work Experience
Demonstrated skills in the areas of negotiation, communication (verbal and written), conflict, creative problem solving, and critical thinking. Knowledge of healthcare financing, community and organizational resources, and data analysis.
Knowledge of utilization management as it relates to third-party payers.
Experience with managed care preferred.
Excellent verbal and written communication skills required.
Demonstrates flexibility via an ability to adapt to changing priorities and regulations.
Basic computer skills required.
Required Skills, Knowledge, and Abilities
• Chart review and excellent communication skills necessary to interact with internal and external staff.
• General idea of governmental and private insurance guidelines.