Denial Management Analyst (Part time 28 hours/week) - Remote

As the Denial Management Analyst this role is the subject matter expert who exhibits excellent skills in the essential components of CDI query opportunity, query compliance, complex pathophysiology and it’s impact/relationship on diagnosis etiology and diagnosis capture for DRG assignment and capture of SOI (Severity of Illness) and ROM (Risk of Mortality). Review, analyze, evaluate and compose a comprehensive rebuttal via the appeal process in a timely manner to the DRG denial claims for clinical and coding denials that are received from the insurer/auditor. Successful appeals result in our upholding the clinical support and the financial reimbursement. Loss of an appeal results in the loss of revenue associated with the denial claim. Work collaboratively with all members of the Healthcare team, Clinical Documentation Integrity (CDI), Coding and Revenue Cycle teams to initiate and resolve Clinical DRG and Coding disparities in dispute from the insurer/auditor. Follow workflow processes to comply with contract requirements. Document in the electronic platform the required components and workflow processes to support initial and all follow up appeal pathways. Identify patterns/trends in denial claims and recognize opportunities for enhancing optimal DRG reconciliation to prevent risk of denial. Educate and support the CDI, Coding teams and Healthcare Provider Services documenting in the UHCare EMR for optimal documentation of clinical indicators for each diagnosis, treatment/monitoring or suspected diagnosis.

Daily DRG Downgrade Processes and Workflow

o Subject matter expert who exhibits excellent skills in the essential components of complex pathophysiology and it’s impact/relationship on diagnosis etiology and diagnosis capture for DRG assignment, financial reimbursement, CDI query opportunity, query compliance, capture of SOI (Severity of Illness) and ROM (Risk of Mortality).

o Serves as a role model, coach, resource for the CDI and Inpatient Coding teams for denial prevention opportunities during concurrent record reviews and during the coding process.

o Performs timely and accurate review of denials, appeal determination and submissions, including tracking findings and outcomes in the designated software tool.

o Remain current with regulatory/payer and internal requirements for processing/submitting appeal claims.

o Documents all appeal activity according to department standards to support accurate and timely reporting of denial and appeal status.

o Independently reviews the denial letter criteria received, reviews the medical record and pertinent documentation, laboratory values, imaging, consultant notes and any other documentation within the encounter that is relevant to the stay and uses expertise of pathophysiology, standard medical criteria for establishing diagnoses, presence of clinical support in the medical record documents for documented diagnosis, coding guidelines, and coding clinics to determine whether to appeal the denial or concur with the denial and loss of revenue.

o Effectively works both independently and as part of a team (CDI, Inpatient Coding, Revenue Cycle, Providers, etc), often in a virtual team environment to collect and compose all pertinent information to create optimally effective appeal letters in defense of the documentation in the medical record that supports a diagnosis and supports successful outcomes.

o Recognizes and acknowledges appropriate escalation and engagement of Physician Advisor during the appeal process and prior to Physician Peer to Peer level to ensure appropriate resolution resulting in expected payment.

o Maintains professional knowledge and expertise by reading and or attending webinars/other educational venues that pertain to CDI, Coding and denial prevention.

o Demonstrates strong professional written and verbal communication skills and excellent grammar, letter composition skills.

o Incorporates current literature, research and best practice into daily practices and when training others.

Education

o Participates in CDI Professional Governance committee, High Reliability Medicine team and/or other hospital based committees as approved by Manager.

o Partners with CDI and Coding Analysts to advance practices focused on clinical denial risk prevention/reduction:

• Provides 1:1 feedback and coaching to CDI or Coder who reviewed case regarding opportunity for improvement

• Demonstrates comprehension of CMI (Case Mix Index) and changes to CMI by reviewing, interpreting, analyzing and evaluating data compiled from departmental statistics from DRGs ( P.Dx and secondary Dxs, comorbid conditions, etc.) on specific service-lines and providers . Provide rationale for trends/impacting factors that impact CMI and develop strategies for correcting/optimizing CMI by developing and providing education/feedback to Providers, CDI and Coding.

• Reviews CDI and Coding DRG reconciliation cases and provides final decisions on cases the CDI and Coding teams are unable to come to reconciliation on, through review of the EMR documentation and the data within the electronic business record, using coding clinics, coding guidelines, and established medical criteria to support diagnosis, being compliant with ACDIS and AHIMA guidelines.

• Identifies via review of the completed medical record during validation of insurer/payor letters of denial any opportunity for clinical and/or coding improvement or query opportunity to enhance the accuracy of documentation and clinical support of diagnoses documented in the EMR to reduce risk of denial. Denial Analyst utilizes best practices and criteria established by credible/regulatory associations (AHA, AHIMA, ACDIS, Medical Associations, CMS, etc.,)

o Facilitates change:

• Supports CDI and Coding leadership teams for change management with active engagement and participation in change process by supporting or leading education, participating in policy development or revisions, continuous review of denial cases through the appeals process with attention to the payor/insurer’s stated rationale.

• Develops and communicates action plan (powerpoints, individual or group feedback, new or revised policies/workflow/best practices/query template revisions, etc) for change management and supports CDI and Coding through change management process

o Denial Analyst escalates cases through the appeal process per insurer/payor established criteria, re-reviewing and researching the details of the denial letter rationale for supporting criteria in the EMR documentation; lab values, imaging reports, surgical procedures, consultations, etc., and compose letter of appeal for submission to the insure/payor for redetermination of benefit(s).

Quality

o Conducts all denial review activities with a focus on continuous quality improvement in a manner that is supportive of UH quality initiatives and in compliance with applicable regulatory requirements

o Reviews cases that the Denial team strongly disagrees with the payor rationale for denial and all levels of appeal have been exhausted in order to determine whether final level of review for a Physician to Physician (Peer to Peer) escalation will be pursued. Prepares for Peer to Peer review in collaboration with Physician Advisor/CDI CMO.

o Collaborates with the CDI, Inpatient Coding leadership and Physician Advisor/CMO to identify patterns/trends of denials by payer, provider/service, diagnosis, DRG, CDI reviewer, Coder and best practice opportunities to enhance denial prevention of those patterns/trends.

o In collaboration with the Denial Leadership and Physician Advisor/CMO, prepares and presents formal and/or informal education for individual or group feedback on denial prevention of identified pattern/trends and opportunities or skill set feedback to prevent/reduce denial trends/patterns.

o Earns and maintains licensures and certifications appropriate to role

o Participates on CDI Department wide projects such as revision of or initiation of new query templates, audit tools, DRG Reconciliation, competencies, assessment tools.

o Identify workflow improvement opportunities (individual or technical) and work to provide potential solutions, resulting in improvement in efficiency, workflow and denial prevention.

o Actively engages with Physician Advisor/CMO, CDI and Coding leadership in advancing CDI and Coding practice throughout UHHS enterprise by developing, modifying, educating, implementing and evaluating new practice behaviors, guidelines and technology enhancements to reduce risk of denials and loss of revenue.

o Participates in Peer to Peer Quality Review process per department standard. (yet to be determined)

o Collaboratively and actively participates in or assists with CDI and Coding DRG Reconciliation processes and provides immediate feedback through the department electronic platform.

o Collaboratively works with the Denial Leadership to orient new employee(s), monitor on-going progress, identify areas for enhanced focus of practice skill and provide support for learning needs, efficiency, proficiency and quality of work

o Other duties as assigned

o May require some travel

Education.

Associate Degree in Nursing or Health Information Management required, Bachelor’s degree preferred.

Required Credentials, License, and / or Certifications.

• RN with current license to practice in the State of Ohio or Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) required.

• Certification in Clinical Documentation Integrity (CCDS or CDIP) and/or Coding Certified (CCS)

Experience & Knowledge:

• 3+ years of experience in inpatient coding and/or CDI required, preferable at a large medical academic center. Must have sound clinical knowledge, strong complex pathophysiology comprehension and up to date knowledge of current industry clinical guidelines required.

• Experience with ICD -10 coding guidelines

• Knowledge of Medicare, Medicaid and Commercial payer regulations preferred

Special Skills & Equipment Knowledge:

• Must be detail-oriented and organized, with good analytical and problem solving ability.

• Notable client service, communication, presentation and relationship building skills required.

• Ability to function independently and as a team player in a fast-paced environment required.

• Must have strong written and verbal communication skills.

• Demonstrated ability to use PCs, Microsoft Office suite, and general office equipment (i.e. printers, copy machine, FAX machine, etc.) required.

• Demonstrated ability to apply concepts, utilize sound judgment and work independently within a framework of guidelines required.

• Coding software proficiency preferred.

This role encounters Protected Health Information (PHI) as part of regular responsibilities. UH employees must abide by all requirements to safely and securely maintain PHI for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.