Denials Specialist TC

Summary:

The Denials Specialist reports to the Manager of PFS Denials Management. Under general direction and within established Lifespan policies and procedures, maximizes reimbursement from contracted payers through analysis, tracking, and trending of denials using available metric denial reports. Responsible for actively supporting the execution of strategic initiatives, process re-design, root cause analysis, metric/report development, and special projects as it relates to denials management. Executes the appeal process by receiving, assessing, documenting, tracking, analyzing, responding to, and/or resolving appeals with third-party payers.

Responsibilities:

ESSENTIAL FUNCTIONS:

Consistently applies the corporate values of respect, honesty and fairness and the constant pursuit of excellence in improving the health status of the people of the region through the provision of customer-friendly, geographically accessible and high-value services within the environment of a comprehensive integrated academic health system. Is responsible for knowing and acting in accordance with the principles of the Lifespan Corporate Compliance Program and Code of Conduct.

Evaluates denied accounts sent to the Denials Management Department for review. Assigns denied accounts to appropriate department workques for resolution. Identifies repetitive issues with the goal of identifying preventative solutions. Runs reports and/or uses workques to identify accounts not worked in a timely manner and follows up with departments when this occurs.

Reviews denial database report when denials are posted to correctly categorize provider liable denials, their root cause, and resolution. Performs end of month reviews of the denial database to identify and report on trends, new issues, areas of opportunity, and any other issues/changes related to the denial report that may be appropriate. Responds to departmental concerns about data on their monthly denial reports.

Develops and maintains a strong working relationship with hospital departments and referring physician offices to collaborate in obtaining information needed for successful appeal/reversal of a denial.

Maintains current knowledge of state and federal regulations, accreditation and compliance requirements, Lifespan policies, as well as payer specific policies including LCDs and NCDs, and payer contracts with Lifespan to identify cause of denials.

Researches payer issues resulting in payment delays, denials, underpayments and processing deficiencies and recommends changes as appropriate. Reviews monthly payer updates, prepare a report of the monthly payer updates to present during the monthly Appeal/Denial meeting.

Tracks the status of appeals by maintaining well organized records to ensure established timelines are met.

Maintains a strong working relationship with payers to assure claims/appeals are processed appropriately.

Processes necessary LifeChart online adjustments or changes related to appeals as needed, within the scope of job function.

Continually evaluates work flow and identifies opportunities to improve process for full and complete payment for all hospital services rendered to patients.

Creates, generates, and maintains ad hoc reports as requested by Manager to assist in the daily operation of the department.

Participates in staff meetings, councils, quality improvement teams and other such meetings and committees as required.

Develops and maintains working relationship with Lifespan affiliate departments as needed to ensure fully data exchange.

Performs other duties as necessary.

WORK LOCATIONS/EXPECTIONS:

After orientation at the Corporate facilities, work is performed based on the following options approved by management and with adherence to a signed telecommuting work agreement and Patient Financial Services Remote Access Policy and Procedure..

• Full time schedule worked in office

• Full time schedule worked in a dedicated space in the home

• Part time schedule in office and in a dedicated space within the home

Schedules must be approved in advance by management who will allow for flexibility that does not interfere with the ability to accomplish all job functions within the said schedule. Staff are required to participate in scheduled meetings and be available to management throughout their scheduled hours. Staff must be signed into Microsoft Teams during their entire shift and communicate with Supervisor as directed.

Other information:

BASIC KNOWLEDGE:

Associate’s degree in accounting, business office practices, computer science or other related area or equivalent experience.

EXPERIENCE:

Three to five years’ experience in hospital patient accounting. Experience should demonstrate thorough knowledge of claims administration in similarly complex healthcare organization. Must be familiar with ICD-9/10, CPT-4 coding, UB04 and HCFA 1500 claims administration. Ability to perform financial analysis. Comprehensive knowledge of patient accounting activities in an automated, networked, multiple hospital environment. Detailed knowledge of regulatory requirements

INDEPENDENT ACTION:

Incumbent functions independently within scope of department policies and practices; refers specific problems to supervisor only when clarification of departmental policies and procedures may be required.

SUPERVISORY RESPONSIBILITIES:

None.

Brown University Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, ethnicity, sexual orientation, ancestry, genetics, gender identity or expression, disability, protected veteran, or marital status. Brown University Health is a VEVRAA Federal Contractor.

Location: Brown University Health Corporate Services, USA:RI:Providence

Work Type: Full Time

Shift: Shift 1

Union: Non-Union