Denials Specialist (FT)

At Ashe Memorial Hospital, we are driven by our Mission Statement, "To meet the needs of the community by delivering patient-centered, high quality health care."

Ashe Memorial Hospital is proud to be Voted Ashe's Best Place to Work 2022 & 2023! Come be a part of our dynamic team; you'll join Ashe's 2022 & 2023 Best Hospital, Best Surgeon, Best Physician, Best Nurse, and Best Medical Practice!  This is your opportunity to make a large difference in a small community!

Hours: 1st shift, Monday through Friday | No Supervisory Responsibilities | No Travel | Pay commensurate with experience

Full time, day shift in the Patient Accounting Department.

JOB SUMMARY:

The Denials Specialist will be responsible for researching, analyzing, resolving and trending rejections and/or denials specific to the revenue cycle. This includes, but is not limited to, analyzing specific denial categories and codes, researching the underlying reason for the denial, rectifying the issue in the patient management system and ensuring that the claim is adjudicated.

The Denials Specialist should be able to identify potential process improvement opportunities and offer recommendations for correcting these issues. The Denials Specialist will be responsible for understanding how all of the various components of the revenue cycle can potentially cause a denial and possible solutions that may result from the interaction of these components. The Denials Specialist will have to be a problem solver and possess the ability to use the resources available to rectify a denial.

The Denials Specialist should be able to analyze Managed Care contracts and reconcile payments received. Contact insurance companies to have adjustments processed and/or file appeals if payments are not in accordance with the contract. The Denials Specialist will have direct interaction with all Supervisors/Managers and/or Department Heads regarding administrative issues related to rejections and/or denials.  Interacts with patients and staff in a professional manner, promotes teamwork, and creates an environment where a positive patient experience is a requirement.

Minimum Job Qualifications:

Education: 

• High school diploma or general education degree (GED) required.
• Associates degree preferred
• Post high school courses in insurance billing, data processing, and medical terminology preferred.
• Three or more years of experience in billing, A/R follow up, denials management & appeal writing.

Experience:

• One year of experience in computerized third-party billing of facility and/or professional services required.
• Knowledge of third-party billing requirements required.
• Two years of previous hospital and/or professional business office experience preferred.
• One year of experience with Meditech and/or SSI preferred.

ESSENTIAL FUNCTIONS:

1. Focus on working complex denials across multiple payers and/or regions
2. Conduct 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
3. Conduct 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
4. Defend and appeal 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.
5. Must also be comfortable communicating denial root cause and resolution to leadership as needed
6. Responsible for aggregating the data that is required and then sending complete appeal packets for every level of appeal either by mail, fax or secured email.
7. Reviewing credit balances and requests from payers. Issuing payer refunds if needed.
8. Actively participate in outstanding customer service and accept responsibility in maintaining relationships that are equally respectful to all
9. Review and resolve accounts assigned via work lists daily as directed by management
10. Tracking and trending of rejection/denial issues
11. Recommendation of alternative contracting rates/terms with the goal to improve net revenue and/or ease the administrative burden associated with the contract terms

12. Maintains confidentiality.

13. Supports the hospital and promotes a positive attitude.

14. Adheres to dress code, appearance is neat and clean.

15. Wears identification while on duty.

16. Adheres to the HIPAA and privacy policies and procedures. Reports any violation or appearance of violation of the policies/procedures and/or laws/regulations addressed in the Compliance Plan/Code of Conduct to the VP of Compliance, Senior Leader, or Department Director.

Skill Set Requirements:

1. Proficient in payment review systems, hospital information systems and coding methodologies.
2. Strong quantitative, analytical and organizational skills.
3. Advanced understanding of an Explanation of Benefits (EOB)
4. Intermediate knowledge of CPT, ICD-10, and HCPCS coding standards
5. Understand CMS Memos and Transmittals.
6. Understand medical records, professional and institutional claims, and the Charge master.
7. Utilize and understand computer technology.
8. Understand all ancillary charges and multi-specialty departmental functions.
9. Understand insurance terms and payment methodologies.
10.Identify accurate Revenue code(s), CPT codes, and HCPCS codes for services/items.
11.Identify clerical error, mistakes in interpretation, imprecise records, and inaccurate service code assignment.
12.Perform reviews for appropriateness of coding and charging, including business office activities, systems       function, and charging methodologies.

Must be willing to receive all required vaccinations (i.e., flu shot, etc.). All new employees working must be fully vaccinated as a condition of employment (unless the new hire has requested and received an exemption). Candidates for employment will be notified of this policy requirement prior to the start of employment. After receiving an offer of employment, new employees must provide proof of vaccination or request and receive an exemption before beginning work.

To apply, please fill out an application, attach a cover letter, and resume. Include gaps in employment and reasons for separation.

Criminal background check and pre-employment drug screen required upon conditional job offer.

***Benefits apply the 1st of the month following employment, per policy.***

*For full job description and benefits, please contact Human Resources.

Ashe Memorial Hospital is an equal opportunity employer and, as such, considers individuals for employment according to their abilities and performance.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising patient care.  Employment decisions are made without regard to race, age, religion, color, sex, national origin, physical or mental disability, marital or veteran status, sexual orientation, genetic information, or any other classification protected by law. All employment requirements mandated by local, state, and federal regulations will be observed.