Denials Coordinator

Job Summary

Ensures that timely, accurate and complete data is submitted to appropriate insurance companies to guarantee prompt payments to Corewell Health. Communicates and collaborates with the multidisciplinary team through verbal and written communication. Participates with Care Team for the integration of the patient to the home or transitional environment by developing, planning, implementing and evaluating in accordance with current existing federal, state and local standards. Adheres to confidentiality policies specific to communications, patient confidentiality, record keeping and coordination services.

Essential Functions

• Understanding of the revenue cycle and the responsibility and goals of each area and how they impact the revenue cycle.

• Review all accounts that have a payer denial based on the Denial Management Policy and Procedure and take appropriate action based on the type of denial.

• Documents all necessary elements; reason for denial/audit, denial status, action taken in the electronic medical record per denial management policy. 

• Understanding of current payer contracts.

• Apply corrections to patient demographics, charges, adjustments, and payments or when needed forwards to the appropriate department for correction.

• Identify and provide communication and education on trends identified.

• Appeal denials based on the appeal criteria found within the Denial Management policy and within appropriate denial due date timeframes.

• Work with facility departs when necessary for resolution or appeal of denials related to that department (i.e Lab, Patient Access, Case Management).

• Prepare and distribute a monthly denial log by facility to include account number, payor type, reason for denial when requested.

• Identifies and communicates monthly denial trends and provides education as necessary to avoid recurring denials for the same denial reason code.

• Send identified medical records as part of the denial/audit process via variety of methods- expedited mail, electronic portal, payor portal or expedited ground currier service. Will document appeal/additional documentation was sent in the electronic medical record once completed. 

• Follows payor or contractor denial/audit rules and timelines as outlined. Performs appropriate follow up with payors on status of appeals/audits. 

• Follows appropriate next steps when denial has been upheld and completes correct adjustment process after the first level of denial is upheld. 

• Maintains a professional image and provides excellent customer service.

• Inputs data from various sources (insurance companies, admissions, certification, and other hospitals) into Care Management discharge planning software and insures communication to members of Care Team.

• Processes and prepares clinical reviews completed by Care Management Department (CMD) employees for confidential transmission to third party payers.

• Maintains ongoing communication between Corewell Health (CH) and third-party payers related to the number of hospital days authorized, additional requests for clinical information, anticipated discharge needs, etc.

• Supports specific third-party payers by obtaining authorization for services; providing accurate & timely admission/discharge dates; updating CMD and SH employees on any demographic changes; problem solving issues/concerns third party payers.

• Maintains expert knowledge of post payment audit and denial issues.  Stays current on trends related to medical necessity, diagnosis-related group (DRG), and automated denials by the recovery audit contract (RAC) and MIP by attending conferences, seminars, audio conferences and online study.

• Utilizes department specific as well as external software applications determined by management to maximize efficiency and effectiveness of department workload.  Develops and maintains databases.

• Maintains a fast-paced process of requests and acknowledgements for data and correspondence.  Identifies and corrects weaknesses in the process and alerts management in the event of potential technical denials due to not meeting date sensitive deadlines.

• Maintains an understanding of many complex and varying guides, systems, regulations and tools.  Utilizes critical thinking skills to manage an ever-evolving process that includes financial, clinical and medical/legal components.

• Develops and implements effective support systems to ensure accurate documentation. Ensures availability of all reports and records for area of responsibility. Prepares reports of post payment audit findings and recommendations for