Facility Appeals Denial Management Specialist

North Oklahoma City billing office looking for an organized, self-motivated, results oriented individual to fill an Appeals Denial Management Specialist position  

Position Summary:

The Appeals/Denial Management Specialist performs daily activities associated with the timely collection and resolution of accounts receivable. This employee is responsible for the resolution of claims that could not be collected or resolved utilizing our standard collection processes.  Responsibilities include, but are not limited to, claim denials, underpayments, coding denials, filing of appeals, zero payments and other claim issues that result in incorrect reimbursement towards outstanding claims.    

Essential Functions: 

• Must possess effective and efficient communication, computer, specifically Microsoft Products and phone skills.
• Must be able to obtain resolution of accounts assigned to the denial/appeals team whether that is collection of additional monies due, resolution of claim issues that resulted in a denial, filing an appropriate appeal and/or any other actions warranted.   
• Responsible for completing any and all required actions to correct billing issues so that claims can be re-filed and processed correctly by the payor.
• Responsible for providing additional information to payors as requested to facilitate claim payment. This includes, but not limited to, medical records, itemized billing, implant invoices, EOBs and card copies.
• Must be able to analyze payments and adjustments to ensure compliance with managed care contracts, timely payment proposals, out of network policies, government payors, commercial payors and state workers compensation schedules.
• Must have an understanding of medical coding and how it relates to reimbursement.
• Expected to maintain knowledge of and adhere to applicable rules, regulations, policies, laws, contracts and guidelines that impact reimbursement and CBO operations. Seeks advice and guidance as necessary to ensure proper understanding.
• Expected to stay informed of the latest developments, advancements and trends in the field of medical collections, appeals and denials by utilizing available resources such as on-line information, reading information provided by payors and attending seminars/workshops as approved by management.
• Must be able to recognize and address issues with payors on behalf of HPI and be able to articulate the issue in the manner needed to resolve the claim. This includes, but is not limited to, formal appeal letters, phone contact to payors/auditors and contact with other departments.
• Employee is expected to maintain a positive and professional relationship with physicians, facilities, co-workers, management, payors and other HPI clients.
• Must exercise independent judgment and be able to analyze and report repetitive denials, payor requirement changes and other instances that affect reimbursement or CBO operations to appropriate party.
• Must be able to solve complex [problematic] reimbursement issues where standard response would not result in optimal reimbursement.
• Must be able to handle stressful situations, multi-task a variety of responsibilities and work under strict timelines.
• Employee is expected to be proficient in all systems, programs and processes associated with their current position within the CBO.
• Effectively working and cooperating with supervisors, co-workers and clients.
• Following the directions of supervisors.
• Refraining from causing or contributing to disruption in the workplace.
• Regular and reliable attendance.
• Performs other duties as assigned.

Functional Accountabilities: 

• Performs insurance and third party payor collections for accounts that have been denied by a payor or the reimbursement received was lower than expected.
• Resolves to completion any and all denied claims assigned to them.
• Review EOBs/correspondence received from other departments to determine reason for denial and appropriate course of action for resolution.
• Contacts third party payors following CBO guidelines established for each payor.
• Correct billing issues and re-file corrected claims to appropriate payor.
• Research, prepare and file written formal appeal with all appropriate attachments to payor stating our expectation on how the claim should be processed.
• Contact payors by phone to request corrected processing, additional information, audits or medical review.
• Completes information requests received from payors for records and other billing documentation.
• Routinely analyzes payment details and correspondence to verify that payors processed our claims correctly.
• Move account balance due from insurance responsibility to patient responsibility when appropriate.
• Submit applicable adjustments when warranted and ensure balance of account is correct.
• Contact offices, facilities and other departments as required to resolve assigned accounts.
• Respond to client requests within 1 business day and/or communicate expected turn around if completion will take longer than one day.
• Familiar with each assigned client and any special handling required for their particular billing.
• Work assigned accounts to completion on a daily basis according to established productivity standards.
• Recognize and report payor trends or issues as they are discovered to management and/or co-workers.
• Make sure all required logs/reports for denial tracking are accurate and completed daily.
• Performs appropriate follow up to insurance payors on previously submitted appeals until a determination is received.
• If initial appeal is denied will file second/third [etc.] level appeals as allowed by insurance incorporating any additional information that could help obtain a favorable outcome.
• Must review all final denials with team lead or manager and receive approval for resolving the account with appropriate adjustment.
• Notes clearly and precisely any and all actions taken on an account in the appropriate notes section of current system.

Requirements: 

• Must have experience with understanding Managed Care, Commercial, Government, Medicaid and Workers Compensation claim determinations. 
• Must have experience with physician/facility billing both office and surgical claims denials and filing of appeals on behalf of provider/facility.
• Must be able to analyze a payer contract and apply rules/reimbursement to a claim, make a determination if a claim is paid correctly and write/file an appeal, if needed.
• Must be able to identify payer trends and research resolutions.
• Coding and anatomy knowledge, medical record review and understanding is a plus.
• Experience with NCCI Edits, bundling and CPT/ICD-10 coding a plus.
• High School Diploma or G.E.D. required.

What We Offer

As an organization, one way we care for our communities and each other is by providing a comprehensive benefits package that includes:

• Medical, dental, vision, and prescription coverage
• Life and AD&D coverage
• Availability of short- and long-term disability
• Flexible financial benefits including FSAs, HSAs, and Daycare FSA.
• 401(k) and access to retirement planning
• Employee Assistance Program (EAP)
• Paid holidays and vacation