Specialist, Denial Management

Responsible for the assessment of denial decisions and preparation of letters using the CMS regulatory standards to communicate decision and alternatives to providers and patients. Acts as a patient advocate in the communication of denial information to the patients and providers to ensure understanding of decision, and that appeal rights are offered in accordance with CMS policy. Is a resource to all medical groups, patients, and providers in the appropriateness of medical necessity, criteria guidelines, and benefit information for national coverage according to the patient's subscriber agreement. The ideal candidate will have excellent investigational skills and understands the importance of meeting deadlines. Candidate will need to work well independently and recognize goals must be met within this quality-based role.

Requirements

• Processes denial information and sorting packets to assign appropriate level of denial packet to the most qualified denial specialist. Handles higher level denial information which usually signifies high-cost service or medical director level of review.
• Prepares denial letters using regulatory format presented to SPCP for the purpose of written communication.
• Interacts with the PCP's office and patients to inform them of alternative care to the requested service of an adverse determination and instructs them of their appeal rights.
• Notifies requesting providers of adverse determinations and instructs them in their appeal rights to be submitted to the health plan.
• Mediates between patient and PCP in order to facilitate medical care requests and concerns directing problematic issues to the health plan grievance committee.
• Maintains denial logs and tracks all auditable information in accordance of National standards
• Researches the CMS national coverage website and Milliman USA to make sure appropriate criteria are available for decisions to be made.
• Interacts with claims to notify and inform proper denial information is sent to providers regarding their payments.
• Enters denials into data entry system for tracking, payment analysis, and decision notification.
• Assists case managers in benefit research information for expedited denial process of inpatients and preparation of letters with urgent delivery to facility.
• Audits data entry process for appropriate communication and text of denial decisions that will be exported as communication on website.
• Resolve zero, partial and over payment denials with various insurance payors.
• Ability to submit secondary claims in a timely manner.
• Research claim denials with the Payers for a resolution that will result in a payment.
• Submit appeals in a timely manner with the proper medical documentation.
• Document notes clearly, concisely and timely to provide full payment resolution.
• Assist with working rejections in claims clearing house and resubmit claims as needed.
• Work on aged accounts receivable.
• Identify issues and trends and communicate to team leads, management as needed.
• Processes write offs/adjustments for non-payable charges according to payer contract.
• Enter information necessary for insurance claims such as patient insurance ID, diagnosis, treatment codes, modifiers to ensure clean claim submissions.
• Ability to read, interpret and explain EOB's.
• Hands on knowledge of CPT and ICD codes
• Excellent phone, communication, organizational skills, computer skills and mathematical skills
• Experience with Microsoft Excel and Word
• Quality
• Directs inappropriate denial decisions to Dir, RCM to report to with presentation of all pertinent medical information.
• Assists in the growth and development of associates by sharing special knowledge with others.
• Attends educational offerings to keep abreast of change and comply with licensing requirements.

Customer Service

• Performs all duties to customers in a prompt, pleasant, professional, and responsible manner regardless of the stressful nature of the situation and always identifies self by name and title.
• Maintains flexibility and enthusiasm and assist others when a staffing problem occurs including assisting other departments with phone coverage and word processing.
• Works closely with the health plan for shared responsibility in appeal process tasks to make sure information and decisions are forwarded timely.
• Preserves a positive working relationship and cooperates well with all departments.

Compliance

• Ensures compliance of entire Denial Process and educates PCP, case managers, referral coordinators, and patients of their responsibilities.
• Assists in audit preparation in pulling files, updating tracking logs, and preparing charts for the auditor.
• Monitors compliance of entire Denial Process and notify delegation manager of any concerning issues.
• Keeps abreast of all new or revised SPCP policies and procedures when posted or distributed and strives to personally expand working knowledge of all aspects of the SPCP departments.
• Ensures all regulatory standards are followed and educate groups where problematic issues arise.

Minimum Required Education, Experience & Skills

• High School diploma or GED required.
• Ability to interact productively with patients, medical group staff, PCP's and specialty providers.
• Sound knowledge of medical terminology, referral process, benefits, claims, contracting issues and regulatory guidelines for denial notification and time frame for processing.
• Independent problem identification and resolution of patient issues originated by adverse determinations regarding medical care in support of PCC decision by education of benefits and criteria standards

Preferred Education, Experience & Skills

• Two years' experience in managed care with HMO health plans, and commercial carriers.
• Experience in physician office specifically with referral management, and pre-authorization of health plan operations.

Physical & Mental Requirements:

Ability to lift up to 10 pounds

Ability to sit for extended periods of time

Ability to use fine motor skills to operate office equipment and/or machinery

Ability to receive and comprehend instructions verbally and/or in writing

Ability to use logical reasoning for simple and complex problem solving