Denials Resolution and Management Specialist- FT- Days- Denials Mgmt

DHR Health - US:TX:Edinburg - Days

Summary:

FLSA STATUS: ☐ Exempt ☒ Non-Exempt

MISSION STATEMENT:

Our Mission is to improve the well-being of those we serve with a commitment to excellence: every patient, every encounter, every time.

VISION:

Our Vision is to create a world-class health system to advance medicine and increase access for the communities we serve by empowering caregivers to heal through compassion, knowledge, innovation, integrated care and excellence.

POSITION SUMMARY:

The Denials Resolutions and Management Specialist is responsible for conducting quality assurance reviews on denied claims. When an appeal is necessary, the specialist drafts appeals to payers using relevant clinical indicators, Official Coding Guidelines, and documentation from the patient's medical record. A thorough understanding of Official ICD-10-CM and CPT/HCPCS Coding Guidelines, CPT Assistant, and CMS directives is essential. Additionally, the specialist plays a crucial role in reporting quality results, tracking and identifying educational opportunities within the Revenue Cycle departments, addressing client subject matter needs, and contributing to educational support and training efforts.

POSITION EDUCATION/ QUALIFICATIONS:
• Education: High School Diploma or GED is required.
• Healthcare Reimbursement Knowledge: Comprehensive understanding of healthcare reimbursement processes.
• Medical Terminology: Proficient in medical terminology.
• EOBs and RAs: Familiarity with Explanation of Benefits (EOBs) and Remittance Advices (RAs).
• Microsoft Office Proficiency: Knowledge of Microsoft Office suite with a working knowledge of Excel required.
• Customer Service: Excellent customer service skills.
• Communication Skills: Strong written and verbal communication skills.
• Multi-tasking: Ability to manage multiple tasks effectively.
• Language Proficiency: Ability to read, write, and speak English.
• Management Communication: Capable of clear and concise communication with all levels of management.
• Bilingual: English/Spanish is preferred.

JOB KNOWLEDGE/EXPERIENCE:
• Healthcare Experience: 2-3 years of previous healthcare experience required, with hospital experience preferred.
• Communication Skills: Communicates clearly and concisely, effectively working with employees, patients, and external parties.
• Customer Relationship Management: Establishes and maintains long-term customer relationships, building rapport with department staff.
• Microsoft Office Proficiency: Demonstrates proficiency in Microsoft Office applications, with a typing speed of at least 35 WPM and strong working knowledge of Excel.
• Mathematical and Written Skills: Capable of performing basic mathematical calculations, balancing and reconciling figures, and ensuring proper punctuation and spelling.
• Medical Coding Knowledge: Knowledge of medical terminology, ICD-9, ICD-10 codes, CPT codes, HCPCS codes, and modifiers required.
• Information Retrieval: Ability to use the internet to obtain information from third-party payers or other sources.
• Focus and Judgment: Capable of working with minimal to moderate interruptions, demonstrating good judgment and reasoning abilities.
• Stress Management: Ability to handle pressure, meet deadlines, and remain productive in challenging situations.

Responsibilities:

POSITION RESPONSIBILITIES:
• Promote Facility Mission: Advocate for the facility's mission, vision, and values by effectively communicating them and incorporating them into service development, standards, and practices.
• Denials and Appeals Proficiency: Demonstrate expertise in handling denials and appeals.
• Create Appeal Letters: Draft detailed appeal letters with all necessary information.
• Follow-Up on Insurance Accounts: Manage and follow up on assigned insurance accounts, ensuring 100% completion of tasks by the end of each week.
• Adhere to Billing Guidelines: Follow governmental billing and collection rules as outlined in Medicare/Medicaid manuals when interacting with insurance carriers.
• Software Proficiency: Utilize Cerner and AX document imaging software efficiently, and access Medicare System-FISS, MyAbility, and Medicaid System-TMHP for eligibility and claim status.
• Billing and Follow-Up: Demonstrate proficiency in billing and following up on Medicare and Medicaid claims using online or billing software.
• Payer Website Access: Access payer websites as needed to retrieve information.
• Type of Bill Familiarity: Recognize when a 121 or 131 Type of Bill is required for ancillary billing and ensure proper account management.
• Managed Care Contract Knowledge: Understand managed care contract terms to determine correct reimbursement levels.
• Reimbursement Comparison: Compare payer reimbursement to expected payments and address discrepancies with insurance carriers.
• Insurance Card Retrieval: Obtain copies of required insurance identification cards.
• Documentation Requests: Contact physician's offices and HIM for necessary documentation and medical records.
• Medical Record Access: Access medical records from the Cerner system for claim appeals.
• Insurance Plans Identification: Identify the correct primary, secondary, or tertiary insurance plans.
• Patient Contact: Contact patients to gather additional information for insurance purposes, if needed.
• Fax and Message Follow-Up: Address faxes or messages from carriers within 24 hours to ensure timely and compliant resolution of denials.
• Customer Service: Provide excellent customer service by responding to carrier or patient calls within 24 hours and documenting all activities on patient accounts.
• Telephone Etiquette: Maintain professional communication and good telephone etiquette with insurance carriers.
• Team Collaboration: Assist team members with challenging accounts as needed.
• Claim Status Knowledge: Stay informed about the current status of claims.
• Account Follow-Up: Follow up on assigned A/R trackers or custom reports, contacting insurance carriers for payment or recoupments.
• Information Requests: Provide detailed instructions when requesting additional information from internal or external departments.
• Paragon Notes: Enter appropriate mnemonics in the Paragon notes tab.
• Tickler Utilization: Use tickler systems for requesting additional information from co-workers or other departments.
• Correspondence Response: Respond to insurance carrier correspondence in a timely manner.
• Insurance Billing: Identify accounts needing insurance billing or rebilling.
• Appeal Management: Enter and maintain appealed accounts through the variable data system.
• PMMC Software: Manage PMMC software for tracking carrier overpayments and underpayments.
• Adjustment Documentation: Select the correct adjustment codes and document adjustments accurately.
• Quality Improvement: Assist in identifying, drafting, implementing, and monitoring quality improvement action plans.
• Compliance Notification: Notify management of any compliance concerns or incidents.
• HIPAA Compliance: Ensure patient confidentiality is maintained in accordance with HIPAA policies and procedures.
• Educational Participation: Attend educational conference calls and complete HealthStream learning modules on time.
• Productivity and Quality: Maintain required productivity and quality standards, and adhere to QA process requirements.
• Cross-Training: Work towards cross-training and familiarizing oneself with both professional and facility denials.
• Additional Duties: Perform other duties as needed for the project.

Other information:

LINES OF REPSONSIBILITIES:

(Chain-of-command)

1. Supervisor → 2. Senior Director → 3. Chief Executive Officer

CUSTOMER SERVICE:

Provide excellent customer service to all DHR customers. All employees are required to attend the DHR C.A.R.E.S program which outlines the Customer Service Principals including: Commitment, Accountability, Respect, Excellence and Service.

AGE SPECIFIC:

Employees must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served in his/her assigned unit. The individual must demonstrate knowledge of principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirement relative to his or her age.

AMERICANS WITH DISABILITIES ACT: (ADA):

A. Essential Duties: Indicated by bold print within performance standards, preceding individual numbered criteria.

The following table provides physical requirements that will be associated with, but not limited to, this position:

Light/moderate lifting up to 20 lbs, from the floor to shoulder height.

Yes

Kneeling

Yes

Must be able to assist other employees with lifting more than 20 lbs.

Yes

Walking

Yes

Light/moderate carrying up to 20 lbs.

Yes

Standing/Squatting

Yes

Straight pulling

Yes

Sitting

Yes

Pulling hand over hand

Yes

Pushing

Yes

Repeated bending

Yes

Stooping/Bending

Yes

Reaching above shoulder

Yes

Climbing Stairs

Yes

Simple grasping

Yes

Climbing Ladders

No

Dual simultaneous grasping

Yes

Depth Perceptions needed

Yes

Ability to see

Yes

Identify Colors

Yes

Operating office equipment

Yes

Twisting

Yes

Operating mechanical equipment

Yes

Crawling

No

Ability to read and write

Yes

Ability to Count

Yes

Ability to hear verbal communication without aid

Yes

Operating Personal Vehicle

Yes

Ability to comprehend written/verbal communication

Yes

Other: Ability to deal with stress

Yes

OSHA Category

III

B. Working Conditions: The individual spends over 95% of his/her time in an air-conditioned environment with varying exposures to noise. There is protection from weather conditions but not necessarily from temperature changes. The position does have low exposure to malodorous, infectious body fluids from patients and some minimal exposure to noxious smells from cleansing agents.

C. Occupational Exposure: This position has minimal to no exposure to blood, body fluids, or tissues and is an OSHA Category III (although situations can be imagined or hypothesized under which anyone, anywhere, might encounter potential exposure to body fluids). Person who performs these duties are not called upon as part of their employment to perform or assist in emergency medical care or first aid or to be potentially exposed in some other way.

D. Aptitudes: HIGH 1 2 3 4 5 6 LOW

Intelligence: General learning ability: The ability to "catch on" or understand instructions and underlying principles. Ability to reason and make judgments. 3

Verbal: Ability to understand meanings of words and ideas associated with them, and to use them effectively. To comprehend language, to understand relationships between words, and to understand meanings of whole sentences and paragraphs. To present information or ideas clearly. 3

Numerical: Ability to perform arithmetic operations quickly and accurately. 2

Spatial: Ability to comprehend forms in space and understands relationships of plane and solid objects. Frequently described as the ability to "visualize" objects or two or three dimensions, or to think visually of geometric forms. 2

Form Perception: Ability to perceive pertinent details and objects or in pictorial or graphic material to make visual comparisons and discriminations and see slight differences in shapes and shadings of figures and widths and lengths of lines. 3

Clerical Perception: Ability to receive pertinent details and verbal or tabular material. To observe differences in copy, to proofread words and numbers, and to avoid perceptual errors in arithmetic computation. 2

Motor Coordination: Ability to coordinate eyes and hands to fingers rapidly and accurately in making precise movements with speed. Ability to make a movement response accurately and quickly. 3

Finger Dexterity: Ability to move hands easily and skillfully. To work with fingers in placing and turning motions. 3

Manual Dexterity: Ability to move hands easily and skillfully. To work with hands in placing and turning motions. 3

Eye-Hand-Foot Coordination: Ability to move the hand and foot coordinately with each other in accordance with visual stimuli. 3

Color Discrimination: Ability to perceive and respond to similarities or differences in colors, shapes, or other values of the same or different color. To identify a particular color, or to recognize harmonious or contrasting color combinations, or to match color adequately. 3

I have read and reviewed my job description with my supervisor or designee and I understand the job I am expected to perform.

If applicable ____________ certification will be completed within _________ time frame of hire/transfer date.

Employee Signature: ________________________________ Date: ____________________

Transfer/Hire Date Effective: ________________________.