Primary Location:

Med Plaza II - UMC

Address:

250 E Liberty Louisville, KY 40202

Shift:

First Shift (United States of America)

Job Description Summary:

About UofL Health:
UofL Health is a fully integrated regional academic health system with nine hospitals, four medical centers, Brown Cancer Center, Eye Institute, nearly 200 physician practice locations, and more than 1,000 providers in Louisville and the surrounding counties, including southern Indiana. Additional access to UofL Health is provided through a partnership with Carroll County Memorial Hospital. Affiliated with the University of Louisville School of Medicine, UofL Health is committed to providing patients with access to the most advanced care available. This includes clinical trials, collaboration on research and the development of new technologies to both save and improve lives. With more than 13,000 team members – physicians, surgeons, nurses, pharmacists, and other highly-skilled health care professionals, UofL Health is focused on one mission: to transform the health of communities we serve through compassionate, innovative, patient-centered care.

Job Description:

Position Summary and Purpose
This position plays an integral role in the recovery of denied reimbursement for hospital services rendered to a patient by providing a comprehensive review of a members’ clinical information and comprising a verbal or written response depicting why the services were medically necessary.  Team members will be responsible for the identification, mitigation, and prevention of clinical denials including medical necessity and authorization issues.  Team members will manage complex patient accounts with precision and accuracy while analyzing medical records to formulate compelling clinical arguments.  Efforts will apply to pre claim edits as well as pre- or post-payment audits from insurance carriers or designated third part vendors.  Team members will interact as needed with internal customers to include but not limited to hospital staff, physicians and their offices, and other revenue cycle team members.  This position will maintain reporting and collaborate with the Payor Relations and Contracting Department during contract negotiations and settlements on denial issues and payment variances impacting payment from third party payers for consideration.
Essential Functions:
Prepare strong appeal letter(s) based on clinical documentation, evidence-based clinical guidelines, and knowledge using nationally accepted criteria, medical literature if applicable, healthcare statutes and payor requirements.  Denial issues may include:  post-discharge medical necessity, DRG validations, retroactive prior authorizations, Recovery Audit Contractor (RAC) and other claim audits.    
Utilizes clinical knowledge and defined standards of care to proactively identify inappropriate admit status based on evidence-based clinical guidelines, i.e. Milliman Clinical Guidelines (MCG) and InterQual Criteria.    
Ensures clinical interventions are appropriate for the admitting diagnosis and reflects the standard of care as defined by the medical staff and health system.     
Analyze medical records or other medical documentation to determine potential for appeal or validate services, tests, supplies, and drugs for accuracy related to the billed charges.     
    
Communicates with physicians and multidisciplinary health system team members to effectively utilize all available resources to ensure a strong and efficient appeal is submitted.    

Shift Requirements:
Shift Length (in hours):    8
# Shifts/Week:    5
Overtime Required:    ☐ Infrequently     ☐ Sometimes    ☐ Often     ☒ n/a (exempt position)

Other Functions:
•    Research commercial and governmental payor policies, regulations, and clinical abstracts related to claims payment to evaluate and appeal denied claims. 
•    Perform timely follow-up on account appeals with understanding of patient accounting documents such as:  UB04, Explanation of Benefits (EOB).
•    Perform retrospective authorization requests for services already performed as needed. 
•    Supports billing staff by reviewing accounts before claim submission to prevent clinical denials. 
•    Assist in tracking/maintaining quantitative and qualitative reviews for data trending, outcomes, and success rate of appeals.
•    Supports global denial prevention and mitigation efforts throughout the health system by attending denial prevention meetings and/or payer representative meetings. 
•    Maintain compliance with all company policies, procedures, and standards of conduct. 
•    Performs other duties as assigned.
 

Additional Job Description:

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