Denials Management Specialist

AdventHealth Corporate

All the benefits and perks you need for you and your family:

• Benefits from Day One

• Career Development

• Whole Person Wellbeing Resources

• Mental Health Resources and Support

Our promise to you:

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Shift: Monday-Friday

Job Location: Remote; Need to be able to go onsite for training, if needed

The role you’ll contribute:

This position is responsible for analyzing payer account reconciliation discrepancies and identifying variance causes for the identification and resolution of payer denials and expected reimbursement underpayments. Responsible for recognizing payer trends to maximize expected reimbursement for the managed care contracts. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all. Under general supervision of the Supervisor of Denials Management, will be responsible for billing and A/R follow up, denial recovery, prevention and appeal writing activities while adhering to the rules and regulations of all government and Managed Care payers in meeting all audit and appeal responsibilities. Performs outgoing calls, corresponds with patients and insurance companies to obtain necessary information, amended or corrected claim resubmissions and communicates with other departments to ensure accurate and timely claim adjudication. This position will be responsible for activities requiring a deep insight into understanding of payer contracts. Adheres to AHS Compliance Plan and to all rules and regulations of all applicable local, state and federal agencies and accrediting bodies.

• Reviews and resolves accounts assigned via work lists daily as directed by management. Focus on working complex denials across multiple payers and/or regions. Conducts account history research as required, including navigating patient encounters and charts, researching charge and payment histories, determining historic account and claim status changes, and researching the payer remittance advice.
• Conducts follow up research on claims to review contract discrepancy and account balances. This may include attaching documentation, amending coverage/patient/encounter/provider/facility data, gathering additional information requests, and resubmitting corrected claims to ensure accurate and timely claim adjudication. Review explanation of benefits (EOB) or, if not present, call the Payor to obtain claims status for denied claims
• Defends and appeals denied claims, including researching underlying root cause, collecting required information or documents, adjusting the account as necessary, resubmitting claims, and all appropriate follow up activities thereafter to ensure adjudication of the claim. Must also be comfortable communicating denial root cause and resolution to leadership as needed.

• Responsible for aggregating the data that is required and then sending complete appeal packets for every level of appeal either by mail, fax or Federal Express utilizing the denials management tool.

• Identifies system loading discrepancies within the contract management system and refers to the Supervisor, Contract Manager or Contract Administrator for correction.

• Thorough understanding of managed care payment methodologies and the principles of managed care. This includes interpreting multiple payment methodologies for payer types such as Commercial Managed Care, Managed Medicare, Managed Medicaid and other governmental payers.

• Identifies payer performance trends by identifying loading inaccuracies at the payer level.

• Responsible for maintaining thorough knowledge of payer financial contract terms and conditions.

• Analyzes daily denial management correspondence to appropriately resolve issues.
• Receives correspondence from all auditing bodies including but not limited to RAC, ADR, MAC, QIC, QIO, ALJ, CERT, ZPIC, OIG, or PROBE, and ensures the appropriate data is documented into RAC Manager and/or the relevant system and maintains records for retrieval upon final audit submission. In addition, will work on all other audits as assigned by the leadership.
• Ensures data accuracy within RAC Manager and relevant denial management tool for each appeal level is accurate that will include data such as dollars at risk, time line assessments and data retrieval for appeals as directed by management.
• Escalates any discrepancies and issues encountered to supervisors in a timely manner. Reaches out to appropriate AHS departments and staff (e.g. patient access, revenue integrity) when additional information and/or expertise is required for accurate claim adjudication. Keeps up to date on department and organization policies and payer regulations.
• Participates in denials management committees and provides updates on denials trends, issues and remediation plans as needed.

• Strives towards meeting and exceeding productivity and quality expectations to align performance with assigned roles and responsibilities. Escalates concerns or difficulties in meeting performance expectations in a timely manner for management action.
• Maintains a positive working relationship with internal staff and external providers, payer representatives and patients and acts in a professional, courteous manner at all times.
• Performs other duties as assigned by management.

The value you’ll bring to the team:

• Comfort with interpreting payer contractual language

• Ability to navigate payer website/portals to perform remittance research and gather additional information needs

• Experience in healthcare claims processing and proficiency with medical billing and remittance forms and processes, including 835 and 837 files, and UB04 and CMS-1500 (HCFA) forms

• Technical proficiency within Patient Accounting systems and denial management workflow technology; position requires ability to navigate various modules within applicable technologies to perform account research

• Exhibits positive ICARE Values & Workforce behaviors: