Denials Resolution Specialist II

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Exemption Status

Non-Exempt

Schedule Details

Monday through Friday

Scheduled Hours

8a to 4p

Shift

1 - Day Shift, 8 Hours (United States of America)

Hours

40

Cost Center

99940 - 5404 Denials

Union

SHARE (State Healthcare and Research Employees)

This position may have a signing bonus available a member of the Recruitment Team will confirm eligibility during the interview process.

Everyone Is a Caregiver

At UMass Memorial Health, everyone is a caregiver – regardless of their title or responsibilities. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve. We are more than 16,000 employees, working together as one health system in a relentless pursuit of healing for our patients, community and each other. And everyone, in their own unique way, plays an important part, every day.

I. Major Responsibilities

• Triages denial root cause and executes appropriate next steps.
• Identifies trends and participates in interdepartmental resolution strategies to reduce and eliminate future denials. Researches complex denials as assigned.
• Trains staff on payer websites, providing basic guidance and instruction on website navigation.
• Uses assigned work queues and prioritization standards and guidelines to perform denial resolution follow up. Work queues assigned will be representative of UMMHC more complex payers.
• Resolves accounts denials with high dollar balances (>$100,00) recognizing the potential complexity and the need for rapid resolution.
• Uses reference material to troubleshoot payer issues and increase understanding of denial resolution techniques. References payer websites as needed.
• Analyzes and researches the denial reasons for each assigned denial code. Recognizes and differentiates between claim denials and payment variances. Initiates appropriate account follow up.
• Participates in payer and internal audits. Supports requests for information, claim correction and/or resubmission. Maintains appropriate documentation related to original audit findings.
• Corrects and updates claim information in the Medicare FISS system requiring in depth knowledge of Medicare billing and compliance regulations.
• Correct and resubmit claims in Mass Health MMIS and other payer websites
• Completes appropriate actions needed for an effective appeal including conducting authorization research, rebilling, and balance write off or transfer to next responsible party. Escalates issues as appropriate.
• Corresponds with third party payers, hospital departments, and patients to obtain information required for denial resolution following payer timelines. Releases information following Federal, State and Hospital guidelines.
• Follows payers established procedures and timelines to submit appeals utilizing payers preferred method, i.e., electronically or via paper.
• Documents all actions taken during the denial resolution process clearly including actions taken, next steps, payer processing timelines, etc.
• Adjusts account balances using correct transaction while code adhering to guidelines.
• Follows established protocols to ensure all documents are retained appropriately.
• Meets established quality and productivity standards.
• Facilitates and promotes the sharing of knowledge and content throughout departments.
• Follows all established Hospital Billing Revenue Cycle Management departmental and compliance policies and procedures.
• Adheres to change control processes.
• Participates in cross training to optimize resources.
• Demonstrates excellent attendance and actively participates in a variety of meetings and training sessions as required.
• Maintains and fosters an organized, clean, and safe work environment.
• Actively contributes to the development and application of process improvements.
• Maintains a collaborative, team relationship with peers and colleagues in order to effectively contribute to the group’s achievement of goals and to help foster a positive work environment.
• Demonstrates respect for the diversity of patient and employee populations. Supports and encourages diverse points of view, work, and lifestyles.
• Practices cost containment and fiscal responsibility through the efficient use of supplies, equipment, time, etc.
• Performs a variety of related duties as assigned by management.
  
  

Standard Staffing Level Responsibilities

• Complies with established departmental policies, procedures and objectives.
• Attends variety of meetings, conferences, seminars as required or directed.
• Demonstrates use of Quality Improvement in daily operations.
• Complies with all health and safety regulations and requirements.
• Respects diverse views and approaches, demonstrates Standards of Respect, and contributes to creating and maintaining an environment of professionalism, tolerance, civility and acceptance toward all employees, patients and visitors.
• Maintains, regular, reliable, and predictable attendance.
• Performs other similar and related duties as required or directed.
  
  

II. Position Qualifications

All responsibilities are essential job functions.

License/Certification/Education

Required:

• A minimum of a High School diploma.
  
  

Experience/Skills

Required:

• Four or more years of experience in health care billing functions.
• Previous health care billing experience.
• Proven track record of successful performance and goal achievement.
• Experience in denial resolution process.
• Advanced knowledge of claim form content and claim submission requirements. Understands and can explain the purpose of revenue codes, condition codes, occurrence codes, modifiers and value codes.
• Proactively proposes resolutions to issues
• Ability to communicate verbally and clearly document all actions taken during resolution process. 8. Demonstrates ability to research denial issues. Can provide root cause of denial issue and identify next steps needed to resolve issue.
• Ability to navigate in MassHealth claims processing application and/or the Medicare claims processing application.
• Experience with high dollar- high complexity claim submissions, i.e. Long length of stay, coverage changes and lapse, coordination of benefit issues
• Ability to work collaboratively and effectively with people.
• Exceptional communication and interpersonal skills.
  
  

Unless certification, licensure or registration is required, an equivalent combination of education and experience which provides proficiency in the areas of responsibility listed in this description may be substituted for the above requirements.

Department-specific competencies and their measurements will be developed and maintained in the individual departments. The competencies will be maintained and attached to the departmental job description. Responsible managers will review competencies with position incumbents.

III. Physical Demands And Environmental Conditions

Work is considered sedentary. Position requires work indoors in a normal office environment.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

We’re striving to make respect a part of everything we do at UMass Memorial Health – for our patients, our community and each other. Our six Standards of Respect are: Acknowledge, Listen, Communicate, Be Responsive, Be a Team Player and Be Kind. If you share these Standards of Respect, we hope you will join our team and help us make respect our standard for everyone, every day.

As an equal opportunity and affirmative action employer, UMass Memorial Health recognizes the power of a diverse community and encourages applications from individuals with varied experiences, perspectives and backgrounds. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, gender identity and expression, protected veteran status or other status protected by law.

If you are unable to submit an application because of incompatible assistive technology or a disability, please contact us at talentacquisition@umassmemorial.org. We will make every effort to respond to your request for disability assistance as soon as possible.