Denials Specialist

Job Description

ECU Health

About ECU Health Medical Center

ECU Health Medical Center, one of four academic medical centers in North Carolina, is the 974-bed flagship hospital for ECU Health and serves as the primary teaching hospital for The Brody School of Medicine at East Carolina University. ECU Health Medical Center has achieved Magnet designation twice and provides acute and intermediate care, rehabilitation and outpatient health services to a 29-county region that is home to more than 1.4 million people.

Position Summary

The Denials Specialist will be responsible for researching, analyzing, resolving and trending rejections and/or denials specific to the revenue cycle. This includes, but is not limited to, analyzing specific denial categories and codes, researching the underlying reason for the denial, rectifying the issue in the patient management system and ensuring that the claim is adjudicated.

The Denials Specialist should be able to identify potential process improvement opportunities and offer recommendations for correcting these issues. The Denials Specialist will be responsible for understanding how all of the various components of the revenue cycle can potentially cause a denial and possible solutions that may result from the interaction of these components. The Denials Specialist will have to be a problem solver and possess the ability to use the resources available to rectify a denial.

The Denials Specialist should be able to analyze Managed Care contracts and reconcile payments received. Contact insurance companies to have adjustments processed and/or file appeals if payments are not in accordance with the contract. The Denials Specialist will have direct interaction with all Managers and/or Department Heads regarding administrative issues related to rejections and/or denials.

Responsibilities

Essential Functions of Role:

1.Focus on working complex denials across multiple payers and/or regions

2.Conduct account history research as required, including navigating patient encounters and charts, researching charge and payment histories, determining historic account and claim status changes, and researching the payer remittance advice

3.Conduct follow up research on claims to review contract discrepancy and account balances. This may include attaching documentation, amending coverage/patient/encounter/provider/facility data, gathering additional information requests, and resubmitting corrected claims to ensure accurate and timely claim adjudication

4.Defend and appeal denied claims, including researching underlying root cause, collecting required information or documents, adjusting the account as necessary, resubmitting claims, and all appropriate follow up activities thereafter to ensure adjudication of the claim.

5.Must also be comfortable communicating denial root cause and resolution to leadership as needed

6.Responsible for aggregating the data that is required and then sending complete appeal packets for every level of appeal either by mail, fax or secured email.

7.Identify system loading discrepancies within the contract management system and refer to the Supervisor and/or Contract Associate Director for correction

8.Adhere to Compliance Plan and to all rules and regulations of all applicable local, state and federal agencies and accrediting bodies

9.Actively participate in outstanding customer service and accept responsibility in maintaining relationships that are equally respectful to all

10. Review and resolve accounts assigned via work lists daily as directed by management

11. Tracking and trending of rejection/denial issues

12. Recommendation of alternative contracting rates/terms with the goal to improve net revenue and/or ease the administrative burden associated with the contract terms

13. Meeting with payers to review methodology and assist in the determination of counter-proposals or settlement resolution.

14. Supporting the Manager and Director as needed

Minimum Requirements

• High school diploma or equivalent
• 5 or more years of experience in billing, A/R follow up, denials management & appeal writing

Skill Set Requirement:

• Proficient in payment review systems, hospital information systems and coding methodologies.

• Strong quantitative, analytical and organizational skills.

• Advanced understanding of an Explanation of Benefits (EOB)

• Intermediate knowledge of CPT, ICD-10, and HCPCS coding standards

• Understand CMS Memos and Transmittals.

• Understand medical records, professional claims, and the Charge master.

• Utilize and understand computer technology.

• Understand all ancillary charges and multi-specialty departmental functions.

• Communicate orally and in written form.

• Understand insurance terms and payment methodologies.

• Work with physicians, administrative staff, and department managers effectively.

• Identify accurate Revenue code(s), CPT codes, and HCPCS codes for services/items.

• Identify clerical error, mistakes in interpretation, imprecise records, and inaccurate service code assignment.

• Perform reviews for appropriateness of coding and charging, including business office activities, systems function, and charging methodologies.

Additional Skill Set Requirement:

• Strong Understanding of the inter-relationships of the Revenue Cycle Departments

• Strong Understanding of Patient Financial Information System and Billing System

General Statement

It is the goal of ECU Health and its entities to employ the most qualified individual who best matches the requirements for the vacant position.

Offers of employment are subject to successful completion of all pre-employment screenings, which may include an occupational health screening, criminal record check, education, reference, and licensure verification.

We value diversity and are proud to be an equal opportunity employer. Decisions of employment are made based on business needs, job requirements and applicant's qualifications without regard to race, color, religion, gender, national origin, disability status, protected veteran status, genetic information and testing, family and medical leave, sexual orientation, gender identity or expression or any other status protected by law. We prohibit retaliation against individuals who bring forth any complaint, orally or in writing, to the employer, or against any individuals who assist or participate in the investigation of any complaint.

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