Overview
The Denial Appeals Specialist functions as a hospital liaison with external third party payers to review denied claims and write appeals for such claims. Audits and coordinates completion of patient records required to retrospectively appeal insurance denials. Evaluate, track and trend denials and implement denial prevention program.
Responsibilities
A. KNOWLEDGE OF WORK
1. Demonstrates competence in the performance of duties and responsibilities related to rights of patients at AHMC Seton Medical Center.
2. Demonstrates competence in the performance of duties and responsibilities related to providing a safe environment in which care and/or service is rendered.
3. Demonstrates competence in the performance of duties and responsibilities related to the application of the Medical Center’s Core Values.
4. Demonstrates competence in the performance of duties and responsibilities related to prevention and control of infection to include blood borne pathogens and TB management.
5.
A. Working knowledge of Title XVII and Title XIX.
B. Working knowledge of reimbursement related to Medicare, Medi-Cal, Capitation, and Managed Care is required.
C. Ability to negotiate orders with the physicians in order to assign alternate levels of care.
D. Working knowledge of community resources.
E. Working knowledge of methods to resolve patient needs such as discharge planning, Home Health, DME and SNF’s.
6.
A. Demonstrates competence in the performance of duties and responsibilities related to patient safety and the performance improvement process.
B. Recognizes indicators and proper reporting of abuse.
C. Practices National Patient Safety Goals (NPSG).
D. Utilizes appropriate methods to prevent falls/wandering.
E. Complies with event reporting, sentinel event procedures, and hospital disclosure policies.
B. DUTIES AND RESPONSIBILITIES
1. Creates a positive first impression.
2. Appeal denials in a timely manner
3. Liaise with Facility Department Directors such as DPS, Case Management and CBO Directors to review, resolve and streamline all necessary aspects of denials
4. Provide education and training to the Medical Staff, Nursing staff and Department Directors on how to prevent Denials
5. Leadership in RAC preparedness and assist facilities in the time of RAC Audits.
6. Liaise and meet with non-compliant payers to resolve issues relating to underpayments or denials. Work with Corporate Contract Manager to review contracts to ensure appropriate reimbursement.
7. Establish appropriate systems for measuring Denial Tracking and Trending
8. Continued Education in current laws that prevent unlawful denials, California Code of Regulations and HMO Compliance. Attend training and develop relevant knowledge and skills.
9. Participate in all Corporate and Facility based Denials Meeting
10. Participate in UR and Medical Staff Dept. Meetings regarding denials and upcoming audits
11. Other responsibilities that the facility and Corporate delegates regarding denials and denials prevention
12. Performs other duties as assigned.
C. INITIATIVE AND JUDGMENT/ATTENDANCE AND RELIABILITY
Independently recognizes and performs duties which need to be done without being directly assigned. Establishes priorities; organizes work and time to meet them.
Recognizes and responds to priorities, accepts changes and new ideas. Has insight into problems and the ability to develop workable alternatives.
Accepts constructive criticism in a positive manner.
Adheres to attendance and punctuality requirements per hospital policy. Provides proper notification for absences and tardiness. Takes corrective action to prevent recurring absences or tardiness.
Uses time effectively and constructively. Does not abuse supplies, equipment, and service.
Observes all hospital and departmental policies governing conduct while at work (e.g., telephone and computer use, electronic messaging, smoking regulations, parking, breaks and other related policies).
SECTION II: SERVICE EXCELLENCE
1. Understands, respects and displays sensitivity to culture, age and persons with disabilities.
2. Participates actively and positively affects the outcomes of customer service activities.
3. Uses effective collaborative strategies as evidenced by:
a) Developing peer relationships that enable the work group to accomplish the daily workload within the allotted time frame and achieve departmental goals.
b) Recognizing and understanding that as a member of an interdependent group, collaboration and compromise is required in order to maintain the effectiveness of the group as a whole to effectively resolve problems.
c) Timely notification to Department Manager/Director of potential problems or concerns. When faced with a problem or concern, is proactive by presenting suggested solutions at the time that the Department Manager/Director is made aware of the problem or concern.
d) Displaying teamwork ability to promote cooperation and collaboration; gaining support for programs and goals.
e) Supports Patient Rights.
4. Displays honesty and respect for others, and respect for the organization as evidenced by:
a) Treating internal and external customers as the most important part of the job.
b) Being sensitive to customer’s emotions, thoughts and feelings.
c) Refraining from negative comments of any kind where the public or other customers can hear.
d) Taking appropriate actions to resolve the concern.
5. Facilitates and enhances communication as evidenced by:
a) Effective and timely processing of customers requests according to hospital and departmental policies.
b) Utilizing verbal communication methods, which enable others to clearly understand what is being said.
c) Utilizing verbal and non-verbal behaviors without being defensive, manipulative, aggressive or controlling.
d) Using written communication that is legible, timely and at a level based on the position specific requirements.
e) Listening attentively to ensure effective two-way communication.
f) Expressing and accepting feedback in a professional manner.
g) Answering the telephone with stating department, name and greeting.
6. Interacts with coworkers, other hospital staff, physicians, and the public in a courteous, professional and efficient manner.
7. Establishes good rapport and working relationships with coworkers, other hospital staff, physicians and the public
8. Observes dress code policy and wears hospital identification as required by our policies and procedures.
SECTION III: CONTINUOUS QUALITY IMPROVEMENT
A. CORPORATE INTEGRITY
1. Understands and abides by all departmental policies and procedures as well as the Codes of Ethics, HIPAA requirements and patient rights.
2. Complies with federal, state, local laws that govern business practices. Complies with all Department of Health Services requirements for the State of California, and HCFA standards that apply to the position.
3. Is knowledgeable and adheres to JCAHO/DHS/CMS standards specific to the position.
4. Participates actively in ensuring that all state and federal rules and regulations are followed as they apply to this position.
5. Conducts business in an ethical and trustworthy manner at all times when dealing with patients, visitors, physicians, and fellow employees.
B. EDUCATION AND ENVIRONMENT OF CARE
1. Attends scheduled inservice and mandatory inservice. Communicates ideas to supervisor for a safer layout of equipment, tools, and/or processes.
2. Follows standard precautions and transmission based precautions as shown by consistent use of appropriate personal protective equipment.
3. Adheres to procedures for the disposal of waste – household waste and biohazard waste as well as the proper disposal of sharps.
4. Uses proper body mechanics and safe patient handling devices at all times. Seeks assistance when necessary to move heavy objects or to transport/transfer a heavy patient.
5. Is knowledgeable in the hospital safety program and takes necessary steps to maintain a safe environment. Adheres to safe work practices in order to prevent injuries and illnesses.
6. Is familiar with emergency codes and emergency preparedness procedures and understands his/her role in response to each of the emergency codes (Code Red, Code Blue, Code Pink, Code Orange, Code Yellow, Code Gray, Code Silver, Code Purple, etc.)
7. Maintains the department in a neat, clean, and orderly manner, especially in own work area.
8. Eliminates or assists in eliminating any seen or known hazards in the workplace. Reports any unsafe conditions to his or her immediate supervisor.
9. Demonstrates good safety habits and judgment by maintaining a safe environment at all times.
10. Complies with all hospital safety and injury prevention policies and regulations (seven Environment of Care plans and hospital safety policies and procedures).
C. PERFORMANCE IMPROVEMENT
1. Understands the Continuous Quality Improvement Process and applies it in performing everyday tasks/duties. Active participant in Continuous Quality Improvement program by assisting in finding new and better ways of performing duties and responsibilities.
2. Understands performance improvement concepts and demonstrates understanding by:
a) Defining performance improvement, and verbalizing at least one major goal of the performance improvement program within the hospital setting.
b) Ability to describe a quality improvement problem solving process (e.g., PDCA) and how its use assists in reaching improving patient outcomes and/or organizational quality improvement goals.
c) Able to verbalize at least one departmental or hospital wide improvement initiative that has occurred within the last 12 months.
3. Cooperates with others in the improvement of services offered at our institution. Continually makes recommendations that assist in the improvement of services.
4. Continually strives for self-improvement in areas of responsibility by attending continuing education classes.
Qualifications
Qualifications
Current RN/LVN License
Minimum five (5) years of medicine/clinical and/or denial/appeal management/utilization review experience in health related setting.
Communication skills: Excellent oral communicator and writing skills
Computer Skills: Excel/Word
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