Denial Management Specialist

Description

STATEMENT OF PURPOSE

Receives, reviews, investigates and refers denials, grievances, and appeals. Gather information on each claim through medical records review, notes, invoices, etc. and prepares appeals summaries while ensuring compliance with organization standards and the regulatory requirements.

This is a full time position working 80 hours per two week pay period. Days of work are Monday - Friday from 8:00am - 4:30pm or 4 10 hours shifts with no nights, weekends or holidays.

JOB FUNCTIONS

• Reviews, interprets, and analyzes denials of insurance claims to determine the cause of the denial such as medical policy, missing authorization, coding issues, etc.
• Facility insurance enrollment-work with insurance companies to provide them with the requested accurately filled out forms and documents to maintain JRMC’s good standing to bill those insurances. Work must be done within timeframes required by insurance companies.
• Works with billers, prior authorization specialists, coders, and providers to appeal denials.
• Respond to all levels of denials by submitting appeal letters and required documentation to insurance companies within the designated payer timeframes.
• Review case history, payer history, and state requirements to determine appeal strategy.
• Obtain patient and/or physician consent and medical records when required by the insurance plan or state.
• Gather and fill out special appeal or review forms.
• Coordinate phone hearings with the insurance company, patient, and physician.
• Comply with all 1st, 2nd, 3rd, and External Level Appeal processes.
• Meet appeal filing deadlines by completing assigned worklist tasks in a timely manner and/or reporting to management when assistance is require to complete the tasks.
• Report all insurance company or state requirements and denial trends to the PFS Manager and Reimbursement Specialist.
• Participate in team and appeal meetings by sharing the details of cases worked.
• Assists with payment posting, resolves clearing house account errors, posting errors, finds missing remits, helps set up website access for payments.
• Backup support to Prior Authorization/ Insurance Verification team.
• Interacts with patients in the adolescent, adult, and geriatric age groups while performing duties.
• Act as backup on answering incoming telephone calls as needed.
• Insurance Biller duties as needed.
• Performs other related duties as assigned or requested.

Requirements

QUALIFICATIONS/REQUIREMENTS FOR THIS POSITION: (DENIALS ANALYST)

1. Preparation and Training - High school level of education preferred; computer and/or secretarial skills.
2. Work Experience - One year clerical experience with computer knowledge with more than three months of progressively more responsible experience required; three months on-the-job training.
3. Attendance - Punctual and regular attendance is an essential responsibility of each employee at JRMC. Employee are expected to report to work as scheduled, on time and prepared to start working. Employees are also expected to remain at work for their entire work schedule.
4. Analytical Ability - Gather and interpret data in unusual situations and solving complex problems; good organizational skills.
5. Independent Judgement - Independent judgment is often required; moderate consequences of errors of judgment.
6. Contacts with Others - Social sensitivity and effective communication is required with public contact and co-workers; compliance to behavior standards is required.
7. Supervising the Work of Others - Manages own work.
8. Responsibility for Welfare of Others - Infrequently provides for the physical well-being of the patient which may result in negligible consequences.
9. Mental / Visual Effort - Must be able to concentrate amid distractions; think clearly under pressure; work regularly requires high level of mental/visual effort. Must be able to speak and write the English language in an understandable manner. Must be in good general health and demonstrate emotional stability. Visual acuity necessary for performing routine procedures.
10. Working Conditions - Works in well-lit office with some inconvenience caused by crowded work area; area subject to temperature discomforts and noise. May be required/requested to work on shifts other than the one for which hired. Works at multiple work stations utilizing a variety of equipment. Participates in and complies with JRMC Safety Management Program. Maintains knowledge of and observes Standard Precautions. Practices aseptic techniques whenever appropriate. OSHA Job Classification: This position is defined as a Category II: Employee does not have exposure to bloodborne pathogens.
11. Physical and Sensory Effort - Must be able to occasionally accomplish movement of computer paper and forms that are a maximum of 50 pounds. Occasional reaching, stooping, bending, kneeling, and crouching. Constant sitting is required to perform the major responsibilities of this job.
12. Promotion - No formal line of promotion.
13. Background Check - A comprehensive background check will be conducted as a condition of employment for this role.
14. Drug Screen - A urine drug screening is required for all positions and must be completed within 30 days of the date of hire.
15. Physical Requirement - These are physical requirements of the position that may be performed as part of daily duties. Inability to meet one or more of these physical requirements will not automatically disqualify a candidate or employee from the position. Upon request for a reasonable accommodation, JRMC may be able to adjust or excuse one or more of these requirements, depending on the requirement, the essential functions to which it relates, and the proposed accommodation.

Employee Requirements

• Visual Observation - Continuously
• Standing - Rarely
• Walking - Occasionally
• Sitting - Continuously
• Hands and Finger Dexterity - Frequently
• Reaching with Hands and Arms - Frequently
• Climbing - Rarely
• Stooping/Kneeling/Crouching/Crawling - Rarely
• Hearing/Listening - Continuously
• Tasting or Smelling - Rarely
• Working Inside - Continuously
• Working Outside - Rarely
• Working in Extreme Heat - Rarely
• Working in Extreme Cold - Rarely
• Working with Hazardous Materials - Rarely
• Noise - Rarely
• Working in Dirt/Dust - Rarely
• Driving - Never

Lifting / Carrying / Pushing / Pulling:

• Up to 10 pounds - Rarely
• Up to 25 pounds - Rarely
• Up to 50 pounds - Never
• Up to 75 pounds - Never
• Up to 100 pounds - Never
• Over 100 pounds - Never