Position Summary The Denials Management Representative is responsible for timely and accurate follow-up and appeal of denials/rejections received from third-party payers. The representative will manage their assigned work to ensure payer appeal/filing deadlines are met and achieve optimal payment for services rendered.# In addition, the representative will review A/R for trends and work to proactively prevent denials based on their analysis.# May be asked to assist within Revenue Cycle and Billing with process improvement.# Essential Duties # Responsibilities include: Monitors denial report in accordance with assignments from direct supervisor. Maintains required levels of productivity while managing tasks in denials report to ensure timeliness of follow-up and appeals. Organizes denial/rejection related tasks to identify patterns and/or work most efficiently (e.g., by current procedural terminology, diagnosis, payer, etc.) Identifies and monitors negative patterns in denials/rejections. Escalates accordingly to management and the impacted department(s) to avoid negative impact on reimbursement, unsuccessful appeals, and/or increased write-offs. As needed, participates in A/R clean-up projects or other projects identified by management.# Works with other departments to resolve A/R and payer issues. Communicates with other departments on issues that may have negative impact on their cash flow, timely claim reconsideration/filing, failed appeals, and/or increased denials and write-offs. Participates in departmental and team meetings involving discussion of A/R processes and trends. Perform timely and accurate review of denials, appeal determination and submission, including tracking findings and outcomes in the designated software tool. Remain current with regulatory / payer and internal requirements. Collaborate with physicians, coders, CDI specialists, insurance follow-up and other members of the Interdisciplinary team and Revenue Cycle to collect all pertinent information and create effective appeals to support successful outcomes, including communication of trends and appropriate escalation to ensure resolution resulting in expected payment. Document appeal activity according to department standards to support accurate and timely reporting of denial and appeal status, outstanding revenue and to help identify trends and educational feedback focused on denial prevention (payer, physician, service, DRG, diagnosis, reviewer). Maintains statistics related to denial activity, including under paid claims. Coordinates and hosts denials management meetings on a regular basis with Revenue Cycle and impacted department staff members. Other duties as assigned by management. # Qualifications High school diploma or equivalent is required.# Associate or Bachelor Degree preferred. Minimum of 1-3 years in a hospital or physician billing office. Knowledge of medical terminology and billing/collection practices. Ability to read and interpret insurance explanation of benefits (EOBs). Knowledge of payer edits, rejections, rules, regulations, and how to appropriately respond to each. Accuracy in identifying the cause of rejections/denials and selecting the most appropriate method for resolution. Demonstrated proficiency with timely and successful appeals to insurance companies. Ability to create professional correspondence to insurance companies and patients. Detail oriented and able to deliver neat and organized work. Self-motivation and ability to demonstrate initiative, excellent time management skills, and organizational capabilities. Must be able to multi-task in a fast-paced environment and appropriately handle overlapping commitments and deadlines. Must be able to work independently and as a team player. Excellent analytical skills and creative problem-solving skills. Strong oral and written communication skills. Demonstrated ability to apply concepts, utilize sound judgment and work independently within a framework of guidelines required.
