Employment Type:

Full time

Shift:

Day Shift

Description:

POSITION PURPOSE

Responsible for reviewing all post-billed denials (inclusive of clinical denials) for medical necessity and appealing them based upon clinical expertise and clinical judgment within the Hospital and/or Medical Group revenue operations ($3-5B NPR) of a Patient Business Services (PBS) center. Serves as part of a team of clinical payment resolution colleagues at an assigned  PBS location responsible for identifying and determining root causes of clinical denials. Responsible for leveraging clinical knowledge and standard procedures to track appeals through first, second, and subsequent levels, and ensuring timely filing of appeals as required by payers, in addition to promoting departmental awareness of clinical best practices. The position will report directly to the Supervisor Clinical / Coding Payment Resolution.

ESSENTIAL FUNCTIONS

Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, and decisions.

Coordinates denial management processes (Clinical and Administrative/Technical accounts, focusing upon retrospective follow-up and appeal processing) with the objective of appropriately maximizing reimbursement based upon services delivered and ensuring that the claim is paid/settled in the most timely manner possible: 

• Supports Supervisor Clinical/Coding Payment Resolution with communication and follow-up processes related to rejections, denials and appeals, ensuring that such activities are tracked, trended and reported to key stakeholders across the various impacted departments
• Coordinates rejection, denial and appeal activities with Ministry Organization (MO) based Utilization Review/Case Management departments;
• Reviews and understands utilization review and coverage guidelines for multiple payers;
• Identifies solutions to issues affecting reimbursement as it relates to denial prevention (prospective and concurrent) and provides summary of findings to Supervisor to deliver feedback to Ministry departments
• Supports the maintenance of a denial management data base, standard report sets, letter template and other key job aids.
• Serves as a resource contact, providing clinical information as requested by payers.  May facilitate coordination information with payers in order to secure appropriate reimbursement;
• Supports Supervisor Clinical/Coding Payment Resolution as the liaison to members of the medical staff and other MO colleagues, regarding denial management processes, systems and requirements.  May provide clinical input to Pre-Service staff in order to facilitate authorization approvals;
• Assists in marketing efforts and the education of physicians, physician office staff and MO colleagues;
• Establishes checks and balances to ensure PBS and MO-based key performance indicators are accurate and that goals/targets are met, and
• Supports the development of effective internal controls that promote adherence to applicable local, state, federal laws, and program requirements of accreditation agencies and health plans.

Identifies opportunities for process improvement and participates in the implementation of such as needed. Assists in the design and development of system enhancements while monitoring congruency with process goals and regulatory mandates.

Maintains a strong working relationship with the associated Ministry Payer Strategy team’s in order to ensure proper identification, resolution, and coordination of clinical denials in alignment with payer environment and expected reimbursement  

Provides detailed understanding or aptitude for resolving denials based on patient status, length of stay, level of care, missing pre-certification, or other clinical reasons and constructing warranted appeals for defined populations as directed by the Supervisor Clinical / Coding Payment Resolution,

Interprets data, draws conclusions, and reviews findings with all levels of Payment Resolution Specialist for further review.

Serve as a resource to Payment Resolution Specialists providing guidance and mentorship in achieving positive operational outcomes.

 Keeps abreast of denial trends and in regulations concerning healthcare financing and payer relations through journals and professional continued education programs, seminars, and workshops.

Other duties as needed and assigned by the Supervisor Clinical / Coding Payment Resolution.

Maintains a working knowledge of applicable Federal, State and local laws/regulations; the Trinity Health Integrity and Compliance Program and Code of Conduct; as well as other p