Summary

Job Summary:Provides ongoing review and management of denied inpatient and outpatient claims; provides support as needed
to Revenue Cycle management and other key customers.

DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: The following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.

1. Reviews all denial accounts for categorization, level of appeal, specific requirements, and root cause.

2. Maintains a clinical appeal process for all inpatient denials assuring that proper documentation is providedto support appeals of unauthorized inpatient days or days denied for lack of documentation.

3. Maintains a clinical appeal process for outpatient denials, i.e., outpatient prior authorization denials,radiology denials, HMO denials for specialty care where a referral was not obtained, and clinicaldocumentation is required.

4. Utilizes denial reports to assess root causes and identify trends; shares findings with stakeholders.

5. Leads a Denial Management Stakeholders team; monitoring identified issues and progress.

6. Work with highest level of appeal cases; refer appropriate cases to Physician Advisors and attorney;consults and collaborates on development of second level appeals.

7. Coordinates all second level appeals that cannot be referred to attorney consultants.

8. Coordinates processing of all appeals at all levels, i.e., initial appeals, second level response, progressreports.

9. Develops training materials, and implements quality assurance processes and serves as a resource tostaff.

10. Identifies areas for improvement regarding department policies and procedures.

11. Provides training to the Denial subgroup who will be initiating rebills and or appeals on behalf of theorganization.

12. Reviews all referred accounts to determine denial categorization, level of appeal required, root causeanalysis, and process steps; provides oversight/assistance for initiating appeals and coordinates complexdenial responses.

13. Provides periodic updates to the Revenue Cycle leadership on the status of denied claims.

14. Assists in the development of a reimbursement error prevention program.

15. Performs other duties as assigned.

Qualifications:

Any combination of education and experience that would likely provide the required knowledge, skills and abilities
as well as possession of any required licenses or certifications is qualifying.

Required Education: High School diploma or equivalent.

Preferred Education: Associates or Bachelors.

Required Experience: Experience in denial management; experience with a healthcare software systemincluding EMR.

Preferred Experience: Experience in applying and utilizing InterQual criteria in appealingreimbursement denials; experience with process improvement methodology.

Preferred Licenses/Certifications: CPC or COC