Become a part of our caring community and help us put health first
 

The Denials Management Specialist is responsible to respond to, monitor and analyze all governmental requests, including but not limited to ADR’s, CERTS, RAC’s, ZPIC’s, SMRC’s, and all other revenue-driven denials and requests. Guides and coordinates with the branch staff in developing responses. Identifies the need for changes in policies, procedures, documentation strategies, and protocols based on regulatory requirements and makes recommendations as indicated.

Essential Functions:

• Responsible for responding to, managing and monitoring all payer requests for additional documentation (ADR), appeals and denials. Works with branch staff to gather required information and ensure timely response to payer requests for additional documentation.

• Monitors denials, collaborates with branch and billing staff to determine appropriate response, manages appeals process.

• Monitors and responds to all requests related to revenue recovery including but not limited to Government and private payer requests.

• Collaborates with branch and billing department staff to develop appropriate and timely responses.

• Responsible for constructing response to denials and appeals, utilizing any federal guidelines or local coverage determination guidelines that are applicable to the record and response.

• Monitors the development, interpretation and implementation of federal and governmental regulations. Coordinates the dissemination of information.

• Provides trended reports for operations and clinical management in order to improve performance, collaborates with and acts as a resource for division and field support staff in identifying areas in need of attention/improvement.

• Identifies the need for new and revised policies and training based on trends, changes in regulations, operations or clinical programs.

• Participates in project team activities, and serves as a backup to divisional regulatory staff on issues of regulations, coverage, compliance and documentation.

• Reviews records and operations as requested regarding compliance with policy and payer requirements.

• Responsible for assigned tasks inside Waystar: entering, tracking, uploading records, etc.

• Participates in and provides training as assigned.

• Performs other related duties as assigned or requested.

Use your skills to make an impact
 

Required Experience/Skills:

• Registered Nurse or Physical Therapist.

• Current state license as a Registered Nurse or Physical Therapist.

• 5 years of professional experience in Home Care, 2 years of which are in an administrative, supervisory, quality assurance or teaching position in/or related to a Medicare certified home health agency.

• A thorough knowledge of federal regulations and Medicare requirements is required along with analytical skills to interpret and apply regulatory requirements.

• Extensive knowledge of home care operations, compliance requirements and legal issues in home care.

• Extensive experience in working with Payer requirements, both traditional Medicare and Medicare Advantage plans, ADR requests, Denials, Appeals, TPE, RCD, RAC, ZPIC, CERT, etc. responses are preferred.

• Excellent written and verbal communications skills.

• Must be able to multi-task and work well under pressure.

• Must be able to learn Homecare Homebase and the Waystar system quickly and extensively.

• Must be proactive, responsive and resourceful.

• Highly flexible and motivated with an ability to work independently as well as in a team setting.

• Must consistently demonstrate the highest level of professionalism and discretion.

• Ability to work a flexible schedule and extended hours on occasion in order to meet deadlines and/or work on special projects.

• Requires working under some stress conditions to meet deadlines and agency needs.

• Must read, write and speak fluent English.

To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.

• Satellite, cellular and microwave connection can be used only if approved by leadership.

• Employees who live and work from Home in the state