Appeals Analyst II

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Position Summary

Responsible for tracking denied claims, work with nurses, payers, outside law firms and other sources to overturn denials on appeal and be an integral part of the effort to obtain payment for services. Works with staff, managers, and administrators in identifying potential problem areas which require improvement, i.e., decreasing costs, increasing revenues, improving workflow in department, facilitating communication, and actively involved with problem-solving. Monitors and maintains current knowledge of any changes in applicable regulations, audit priorities, health insurance trends focused on those specifically applicable to the Medical Center and advises the Senior Director on changes and appropriate preventative strategies for financial risk management. Represents the Denial & Revenue Integrity Department and the Medical Center at Health System Committees for denial & appeal management. Position responsibilities will vary slightly depending on focus (Medicare versus Commercial).

Location: 100% Remote

Hours: Days, 40 hours

Accountable For:

In addition, this position is responsible for:

• Develop and maintain tracking system for identifying all denials and appeals.
• Complete routine analysis of data to identify trends and works with the team and leadership to develop action plans.
• Manage medical record request to assure information is transmitted timely and appropriately.
• Establish a process for referring denials to an outsource (RN, legal firm) for appeal.
• Conduct appeal based on substance of denial; use guidelines to help in appeal process; track activity for timeliness and effectiveness.
• Maintain relationships with department Physician Advisors: provide support in resolving administrative issues associated with reviews.
• Communicate with various external departments including: Financial Clearance, Billing, HIM, Pharmacy, and Clinical areas.
• Responsible for monitoring, tracking, and reporting Utilization Review processes necessary to ensure compliance with appropriate standards and regulations to prevent avoidable losses through audits and denials of payment.
• Assists the leadership with ad hoc projects.
• Work in partnership with Care Management department systems administrator to make modifications to improve the functionality of the utilization review tracking software.
• May perform in-service education under supervision with physicians, nurses, and others regarding UM issues.
• Create, maintain, and develop reports of departmental data bases, i.e., database for tracking charity care patients and the database of payor contacts.
• Facilitates team building for problem solving, goal formation, conflict-resolution, and negotiation to maximize team performance.
• Conducts periodic audits and staff training.
• Using critical thinking skills, evaluates and recommends workflow process improvements within the departments involved in audits, denials, and appeals, considering parallel processes in other entities as appropriate.
• Communicates and coordinates with authorities and payers on audits, denials and appeals by maintaining direct contacts, being proactive in addressing issues, and initiating follow up.

Qualifications

Education: Bachelor's degree in Business, Health Administration, or related field or equivalent of 8 years of work experience.

Work Experience: Five to seven years of relevant experience in a health care or professional billing.

Knowledge:

• Experience in claims processing, third party billing, patient accounts management required.
• Significant experience with word processing, spreadsheets, and graphics.
• Experience in data analysis and report production.
• Must be computer literate and able to learn the multiple systems used for patient registration and billing on all campuses. Familiarity with medical records coding and charting practices is necessary.
• Excellent interpersonal skills to handle sensitive and confidential information. Must possess excellent communication skills to gather and exchange data.
• Must serve as liaison between various departments on issues regarding registration, coding, medical record documentation, and appeals efforts.
• Able to gather and interpret data from multiple sources and resolve problems.

Skills

• May serve as a liaison with third party payers to establish sound working relationships and communication channels.
• Highly proficient in developing and utilizing spreadsheets and graphics to manipulate large data sets.
• Displays judgment in reviewing accounts to determine appropriate resolution.
• Strong ability to analyze and trend of statistical data to target sources of denial.
• Strong ability to produce reports tracking denied and overturned accounts and communicate findings.
• Strong ability to produce comprehensive and concise, executive-level reports on an ad-hoc basis within tight time constraints.
• Formulates action plans for denial resolution in conjunction with various departments.
• Possesses excellent written and verbal communication skills necessary to gather and exchange data (both internal and external) with key professionals.
• Possesses excellent interpersonal skills and ability to handle sensitive and confidential information.
• Works with Department Administrators, Clinic Managers, and Patient Accounting to design workflows to minimize denials, resubmit claims, as needed, and update host systems.
• Work requires attention to detail and requires mental/visual acuity.
• Must be able to facilitate communication cross-departmentally concerning administrative denials.
• Must successfully interact with other departments, including Billing, Appeals, the Office of Managed Care, Financial Clearance, Utilization Management, Patient Accounting, and other Financial departments.

Salary Range: Minimum 26.12/hour - Maximum 43.11/hour. Compensation will be commensurate with equity and experience for roles of similar scope and responsibility.

In cases where the range is displayed as a $0 amount, salary discussions will occur during candidate screening calls, before any subsequent compensation discussion is held between the candidate and any hiring authority.

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