Job Summary:
Reviews inpatient and outpatient payer denials and initiates appeals with insurance companies. Performs initial claim denial root cause analysis which entails completing the necessary steps to respond and resolve the denial. This position will actively manage, maintain and communicate denial/appeal activity and trends to appropriate revenue cycle stakeholders (i.e. CDI, PFS, Physicians). Conducts review of claims issues and denials that are related to billing edits. Investigates coding/charging/billing processes to ensure claim and reimbursement accuracy. May be requested to do Inpatient Coding during high census or to cover other coder absences.
Service and Quality Standards:
- Service
Is Customer focused
Anticipates customer needs
Adheres to customer service standards
Is Competent, caring and compassionate
Treats coworkers and customers with dignity and respect
Demonstrates competent, caring and compassionate behavior
to customers and coworkers
- People
Is conversation conscious?
Assures confidentiality of patient and employee information
Is positive in interactions with others
Is courteous and respectful
Promotes a harassment free environment
Inspires the trust of others
Acts in accordance with hospital policies, meets the requirements of the Code of Conduct, and identifies any conflicts of interest.
- Quality
Is excellent in patient care and service
Demonstrates multidisciplinary cooperation
Assists in obtaining excellent satisfaction scores of feedback
Is safety conscious?
Demonstrates safety consciousness and supports safety initatives
Is involved with improvement efforts
Supports performance improvement
Seeks ways to improve systems and services
Shows commitment to improvement efforts
Meets mandatory educational requirements
- Growth
Is a loyal ambassador
Demonstrates commitment to hospital mission and vision
Is active and involved
Supports hospital initiatives
Champions innovation and supports change
Is a positive role model
Fosters team cooperation
- Finance
Is a good steward of hospital resources
Develops/uses efficient work methods
Is cost effective
Conserves organizational resources
Job Responsibilities:
Reviews payer inpatient and outpatient denials and writes appeal letters and/or responds to payers with review outcomes. Submit detailed, customized appeals to payers based on review of medical records and in accordance with Medicare, Medicaid, and third-party guidelines.
Tracks inpatient denial and appeal activity using an Excel spreadsheet.
Research payer edits and denials related to medical necessity and other payer coding requirements, i.e. CMS, Medicaid.
Make recommendations for additions/revisions/deletions to work queues and claim edits to improve efficiency and reduce denials.
Demonstrates initiative and resourcefulness by communicating results of claims review activity to CDI, Physicians, and revenue cycle stakeholders (i.e. PFS, Revenue Systems)
Attends insurance update meetings, provides synopsis of bulletins and notifies impacted areas, i.e. Payer Alerts.
Consults with departments throughout the system on charge processes to ensure appropriate use of codes and modifiers.
Identifies denial trends and follows-up on root causes to prevent further denials.
