Denials Specialist TC

Summary

Brown University Health operates a comprehensive integrated academic health system providing patient-focused healthcare services. The Denials Specialist analyzes, tracks, and trends payer denials, manages appeals, performs root cause analysis, and supports process improvements to maximize reimbursement. The role also collaborates with hospital departments and payers, maintains denial records, and prepares reports on payer issues and denial trends.

Responsibilities

• Consistently applies the corporate values of respect, honesty and fairness and the constant pursuit of excellence in improving the health status of the people of the region through the provision of customer-friendly, geographically accessible and high-value services within the environment of a comprehensive integrated academic health system
• Is responsible for knowing and acting in accordance with the principles of the Brown University Health Corporate Compliance Program and Code of Conduct
• Evaluates denied accounts sent to the Denials Management Department for review
• Assigns denied accounts to appropriate department workques for resolution
• Identifies repetitive issues with the goal of identifying preventative solutions
• Runs reports and/or uses workques to identify accounts not worked in a timely manner and follows up with departments when this occurs
• Reviews denial database report when denials are posted to correctly categorize provider liable denials, their root cause, and resolution
• Performs end of month reviews of the denial database to identify and report on trends, new issues, areas of opportunity, and any other issues/changes related to the denial report that may be appropriate
• Responds to departmental concerns about data on their monthly denial reports
• Develops and maintains a strong working relationship with hospital departments and referring physician offices to collaborate in obtaining information needed for successful appeal/reversal of a denial
• Maintains current knowledge of state and federal regulations, accreditation and compliance requirements, Brown University Health policies, as well as payer specific policies including LCDs and NCDs, and payer contracts with Brown University Health to identify cause of denials
• Researches payer issues resulting in payment delays, denials, underpayments and processing deficiencies and recommends changes as appropriate
• Reviews monthly payer updates, prepare a report of the monthly payer updates to present during the monthly Appeal/Denial meeting
• Tracks the status of appeals by maintaining well organized records to ensure established timelines are met
• Maintains a strong working relationship with payers to assure claimsppeals are processed appropriately
• Processes necessary LifeChart online adjustments or changes related to appeals as needed, within the scope of job function
• Continually evaluates work flow and identifies opportunities to improve process for full and complete payment for all hospital services rendered to patients
• Creates, generates, and maintains ad hoc reports as requested by Manager to assist in the daily operation of the department
• Participates in staff meetings, councils, quality improvement teams and other such meetings and committees as required
• Develops and maintains working relationship with Brown University Health affiliate departments as needed to ensure fully data exchange
• Performs other duties as necessary

Skills

• Associate's degree in accounting, business office practices, computer science or other related area or equivalent experience
• Three to five years' experience in hospital patient accounting
• Experience should demonstrate thorough knowledge of claims administration in similarly complex healthcare organization
• Must be familiar with ICD-9/10, CPT-4 coding, UB04 and HCFA 1500 claims administration
• Ability to perform financial analysis
• Comprehensive knowledge of patient accounting activities in an automated, networked, multiple hospital environment
• Detailed knowledge of regulatory requirements

Qualifications

Must Haves

• Associate's degree in accounting, business office practices, computer science or other related area or equivalent experience
• Three to five years' experience in hospital patient accounting
• Experience should demonstrate thorough knowledge of claims administration in similarly complex healthcare organization
• Must be familiar with ICD-9/10, CPT-4 coding, UB04 and HCFA 1500 claims administration
• Ability to perform financial analysis
• Comprehensive knowledge of patient accounting activities in an automated, networked, multiple hospital environment
• Detailed knowledge of regulatory requirements

Benefits

• After orientation at the Corporate facilities, work may be performed full time in the office, full time in a dedicated space in the home, or part time in the office and in a dedicated space within the home, subject to management approval and a signed telecommuting work agreement.
• Schedules approved in advance by management allow for flexibility that does not interfere with the ability to accomplish all job functions within the schedule.