Patient Access Coordinator - Denials Management

JOB PURPOSE OR MISSION:  Provides excellent customer service during the denial/appeals process, executing patient access through the continuum of the revenue cycle that supports efficiency, cost reduction and service improvement.  Performs duties according to established hospital procedures for the age population served, as defined in the department’s scope of service.

PERFORMANCE CRITERIA

CRITERIA A:  Everyday Excellence Values – Employee demonstrates Everyday Excellence values in the day-to-day performance of the job. 

PERFORMANCE STANDARDS:

Demonstrates courtesy and caring to each other, patients and their families, physicians, and the community. Takes initiative in living our Everyday Excellence values and vital signs. Takes initiative in identifying customer needs before the customer asks. Participates in teamwork willingly and with enthusiasm. Demonstrates respect for the dignity and privacy needs of customers through personal action and attention to the environment of care. Keeps customers informed, answers customer questions and anticipates information needs of customers.

CRITERIA B:  Corporate Compliance – Employee demonstrates commitment to the Code of Conduct, Conflict of Interest Guidelines, and the GHS Corporate Compliance Guidelines.

PERFORMANCE STANDARDS:

Practices diligence in fulfilling the regulatory and legal requirements of the position and department. Maintains accurate and reliable patient/organizational records. Maintains professional relationships with appropriate officials; communicates honestly and completely; behaves in a fair and nondiscriminatory manner in all professional contacts.

CRITERIA C:  Personal Achievement – Employee demonstrates initiative in achieving work goals and meeting personal objectives.

PERFORMANCE STANDARDS:

Uses accepted procedures and practices to complete assignments.  Uses creative and proactive solutions to achieve objectives even when workload and demands are high. Adheres to high moral principles of honesty, loyalty, sincerity, and fairness. Upholds the ethical standards of the organization.

CRITERIA D:  Performance Improvement – Employee actively participates in Performance Improvement activities quality improvement standards in his/her job performance.

PERFORMANCE STANDARDS:

Optimizes talents, skills, and abilities in achieving excellence in meeting and exceeding customer expectations. Initiates or redesigns to continuously improve work processes.

Contributes ideas and suggestions to improve approaches to work processes. Willingly participates in organization and/or department quality initiatives.

CRITERIA E:  Cost Management – Employee demonstrates effective cost management practices.

PERFORMANCE STANDARDS:

Effectively manages time and resources. Makes conscious effort to effectively utilize the resources of the organization – material, human, and financial. Consistently looks for and uses resources saving processes.

CRITERIA F:  Patient & Employee Safety – Employee actively participates in and demonstrates effective patient and employee safety practices. 

PERFORMANCE STANDARDS:

Employee effectively communicates, demonstrates, coordinates and emphasizes patient and employee safety. Employee proactively reports errors, potential errors, injuries or potential injuries. Employee demonstrates departmental specific patient and employee safety standards at all times. Employee demonstrates the use of proper safety techniques, equipment and devices and follows safety policies, procedures and plans.

JOB FUNCTIONS

ESSENTIAL JOB FUNCTIONS include, but are not limited to:

Denials/Appeals

PERFORMANCE STANDARDS:

Investigate all administrative, coding and clinical validation denials and medical necessity acute denials referred by Patient Financial Services (PFS) or issued by federal and commercial payors. Plan appeal strategy and submit the denial nurses written appeal within the payor’s required appeal timeframe with supporting documentation using the payor’s required appeal format and procedures. Investigate and/or maintain follow-up status on all appeals mailed to federal and commercial payors via payer portals or telephonically. Collaborate and assist the denial team with other department denials/appeals. Collaborate with the revenue cycle team, including patient financial services (PFS).

Denial Data Retrieval, Analysis and Education

      PERFORMANCE STANDARDS:

Maintain accurate denial information on denial SmartSheet and in electronic software, following the denial team set process. Record commercial payor denial concerns and attend payer/provider representative meetings, as needed. Record and trend patterns of denials by payor, physician and/or hospital department.          

Department liaison to Patient Financial Services (PFS) Department.

PERFORMANCE STANDARDS:

Collaborate with revenue cycle team, including patient financial services. Attend the bi-weekly denial call and report current status of all active denials.

Performs all other duties as assigned.

EXPERIENCE REQUIREMENTS

Hospital experience is essential with basic knowledge of medical terminology or clinical experience.

EDUCATIONAL REQUIREMENTS

High school or associate degree required; bachelor’s degree preferred.

Equivalent work experience supporting professional staff activities may be substituted.

SPECIAL SKILL AND KNOWLEDGE REQUIREMENTS

Preferred knowledge of current reimbursement models:  Commercial, Managed Care, Medicare, and/or Medicaid.

Strong analytic, data management, and computer skills.

Excellent interpersonal communication and negotiation skills.

Ability to manage multiple priorities.

HIPAA REQUIREMENTS:

Maintains knowledge of and adherence to all applicable HIPAA regulations appropriate to Job Position including but not limited to: Paper and electronic medical records without limitation, patient demographics, lab and radiology results, surgery/appointment schedules, medical records related to quality/data, patient financial, 3 rd party billing information, patients related complaints, information related to patient location, research information, investigatory information, and/or access to physician specific data related to outcomes.

SAFETY REQUIREMENTS:

Maintains knowledge of and adherence to all applicable safety practices appropriate to Job Position including but not limited to: Incident reporting, exposure control plans, hand washing, environmental rounds to ensure safety, and patient identification.

Full-Time