Denials and Appeals Coordinator
Company: Washington Hospital Healthcare System
Location: Fremont
Posted on: June 24, 2022
Job Description:
Job DescriptionDivision: Quality and Resource ManagementJob
Title: Denials and Appeals CoordinatorJob Code:Position
SummaryReporting to the Director of Case Management, with the
support and direction of thePhysician Advisorand the Chief of
Quality and Resource Management, functions as a hospital liaison
with external third-party payors to appeal denied claims and
retrospectively pre-certify accounts as indicated. Research and
coordinates completion of patient records required to
retrospectively pre certify accounts and appeal insurance denials
as needed. Identifies areas for documentation and/or process
improvement and promotes pro-active documentation compliance for
reimbursement. Works with Finance and Revenue Cycle Team on appeal
process and denials prevention. Demonstrates dynamic ability to
adapt to ongoing changes within the health insurance industry in
order to effect and implement positive changes for the financial
growth of WHHS. Accepts projects as assigned.In addition to
performing the essential functions listed below, may also be
assigned other duties as required.Statement of
AccountabilityReports to: Director of Case Management1Job
Description/Denials and Appeals Coordinator-
2/21/22Qualifications
- Education
- Licensure
- Work Experience
- Skills/computer/ specific technical
- Other qualifications, miscellaneousSpecify if qualifications
are Required or Preferred
- Bachelor of Science in Nursing
- California Registered Nurse License
- Four years clinical experience as a Registered Nurse
- Three years with progressive experience in Utilization
Review
- Knowledgeable of payors and WHHS Managed Care contracts
- Basic computer skills required
- Demonstrates effective interpersonal and communication
skills
- Demonstrates flexibility via an ability to adapt to changing
priorities
- Demonstrates good customer relations
- Ability to prioritize assignments and effective time-management
skills
- Must be detail oriented, flexible, and committed to patient
advocacy
- Demonstrates skills in planning, organizing, and managing.
Multiple functions and complex processes
- Excellent verbal and written communication skills required
- Knowledge of basic computer software programsEssential Job
ResponsibilitiesAchieving ResultsKey Components: assess, plan,
evaluate, demonstrate initiative, quality of work,
productivity
- Coordinatesall clinical denial management activities to
successfully appeal and recoup payments to the organization.
- Under the direction of the Physician Advisor writes the appeal
letter, coordinates with HIM to obtain the entire medical record to
ensure deliverance to payor, while maintaining a tracking
system.
- Ensures timely follow-up once an appeal has been sent to
determine the status of the appeal and when appropriate, continue
appealing until denial is no longer appealable.
- Responsible for concurrent denials working with the physician
advisor for denial prevention.
- Assists with Epic Work Queues to resolve issues timely
- Evaluates denials to determine root cause and implement
activities to avoid denials from occurring and trend to ensure
compliance
- Prioritizes overturn activities using a range of cause factors
including denials reason codes, payors, physicians, procedures, and
services to ensure efforts are focused where they will have the
best financial impact for the organization
- Documents all activities in individual patient accounts using
comments, reminders, and smart phrase functionality. Tracks ongoing
financial returns resulting from appeals activityWrites and updates
detailed procedures on all processes maintaining accuracy,
integrity, and completenessDemonstrates SkillKey Components:
competency, job knowledge, organizational skills, analytical skill,
management of information, employee & patient safety
- Expert in MCG and assist in the education of case managers,
when requested
- Maintains an understanding of the Patient Access System and
Patient Accounting in order to identify internal issues that could
cause a denial
- Maintains an understanding of payor reimbursement to third
party payors and governmental agencies such as Medicare, MediCal
and Tricare
- Maintains an understanding of all Managed Care Agreement and
the contracted rates
- Distributes up to date information and changes from payors to
case management staff
- Applies understanding of payor reimbursement and contracted
terms/rates to identify incorrectly paid or denied claims that
require an appeal to be done.Planning & CoordinatingKey Components:
delegates, decision making, problem solving, management of
resources
- Reviews reports with Director to determine trends, education
opportunities, action plans, and compliance with any changes in
processes and procedures
- Applies understanding of payor reimbursements and contracted
terms/rates to identify incorrectly paid or denied claims that
require an appeal to be done
- Responsible for arranging timely peer to peer reviews with
commercial payorsProfessionalismKey Components: dependability,
interpersonal skills, teamwork, patient first ethic, customer
service, communication skills, punctuality/attendance,
receptiveness to criticism, judgment, confidentiality
- Moves beyond task-based orientation to role-based practice and
focuses attention or professional role, authority, responsibility
and accountability.
- Exercises decision authority and demonstrates
self-direction
- Acts in a manner that promotes dialogue, open communication,
and positive working relationships
- Strengthens role-based professional practice within the
multidisciplinary teamImproving the OrganizationKey Components:
performance improvement, quality initiatives
- Responsible for departmental orientation program for current
and new Case Management staff to understand the denial process and
opportunities to improve communication with payors to avoid
denials.
- Interfaces with Finance Department as a leader, consultant, and
participant in inter/intradepartmental meetings and
committees.
- Assists other hospital departments in process improvements to
eliminate denials of their servicesSelf-DevelopmentKey Components:
maintain license/certification, education and training
- Annual review of medical criteria (MCG)competency, including
Inter-Rater Reliability (IRR)
- Maintains an awareness of self-responsibility and
accountability for improving own level of practice.Regulatory
ComplianceKey Components: JCAHO, Title 22, OIG, HIPAA,
State/Federal laws, hospital policies
- Maintains basic understanding of all CMSConditions of
Participation.
- Demonstrates awareness of and compliance with Joint Commission,
Title 22, OSHA, HSAG, EMTALA, HIPAA and other service specific
regulations.
- Cross trained to perform review of all discharges of Medicare
one day stays to ensure compliance with the Two Midnight rule and
follow-up appropriately, using if necessary 121 Bill Type, A to B
rebill as well as Span Code 72.1Job Description/Denials and Appeals
Coordinator- 2/21/22Prepared by:Title: Date: Approved by:Title:
Date:Personnel Office Review:Date:Revised Date:1Job
Description/Denials and Appeals Coordinator- 2/21/22Physical
RequirementsJob # Job Title Denials and Appeals Coordinator
- Physical Activities - General description. Show average time (0
- 8 hours) per workday.
- Sitting: None/minimal (0-1) Occasional (1-2) Frequent (3-4)
Continuous (5+ Hrs)
- Walking: None/minimal (0-1) Occasional (1-2) Frequent (3-4)
Continuous (5+ Hrs)
- Standing: None/minimal (0-1) Occasional (1-2) Frequent (3-4)
Continuous (5+ Hrs)
- Bending: None/minimal (0-1) Occasional (1-2) Frequent (3-4)
Continuous (5+ Hrs)
- Squat, kneel, None/minimal (0-1) Occasional (1-2) Frequent
(3-4) Continuous (5+ Hrs) crawl:
- Weight lifted / force exerted. Show average time (0 - 8 hours)
per workday:
- 0 -25 lbs. (light): None/minimal (0-1) Occasional (1-2)
Frequent (3-4) Continuous (5+ Hrs)
- 26 - 50 lbs. (med): None/minimal (0-1) Occasional (1-2)
Frequent (3-4) Continuous (5+ Hrs)
- 51 + lbs. (heavy): None/minimal (0-1) Occasional (1-2) Frequent
(3-4) Continuous (5+ Hrs)
- Describe type of activity: Pushing/Pulling Reaching above
shoulder level Lifting Carrying.
- Details of heaviest item/activity:
- Repetitive use of hands. Show average (0 - 8 hours) /
workday:
- Both hands: None/minimal (0-1) Occasional (1-2) Frequent (3-4)
Continuous (5+ Hrs)
- Dominant only: None/minimal (0-1) Occasional (1-2) Frequent
(3-4) Continuous (5+ Hrs))
- Dexterity: Simple grasping Power grasping Fine
manipulation.Describe any special activity:
- Repetitive use of feet (other than walking/standing), i.e. foot
control.Show averagetime (0 - 8 hours)workday:
- Right Left Both None/minimal (0-1) Occasional (1-2) Frequent
(3-4) Continuous (5+ Hrs)Describe any special activity:
- Vision requirements: Basic Vision Requirements; including Close
Vision (clear vision at 20 inches or less) and Distance Vision
(clear at 20 feet or more). 1Job Description/Denials and Appeals
Coordinator- 2/21/22Specific Vision Requirements:
- Color Vision (ability to identify and distinguish colors)
- Peripheral Vision (ability to observe up/down or left/right
whileeyes are fixed on a given point)
- Depth Perception (three-dimensional vision; ability to judge
distances and spatial relationships)1Job Description/Denials and
Appeals Coordinator- 2/21/22Describe any special vision
requirement:
- Hearing requirements: Basic Hearing Requirements; including
ability to hear alarms and pages, ability to hear communications,
requests or instructions from patients, staff or public.1Job
Description/Denials and Appeals Coordinator- 2/21/22Describe any
special hearing requirement:
- Work Environment - This job requires exposure to the following
environmental conditions:
- Blood or body fluids e. Toxic or caustic chemicalsi. Electrical
shock risk.
- Wet, humid conditions (non-weather) f. Outdoor weather
conditionsj. Risk of radiation
- Work near moving mechanical parts g. Extreme cold
(non-weather)k. Vibration
- Fumes or airborne particles h. Extreme heat (non-weather)
- Noise level for work environment is: Very Quiet Quiet Moderate
Loud Very Loud
- Other (if applicable):1Job Description/Denials and Appeals
Coordinator- 2/21/22Remember to update header & footerJob Hazard
AnalysisDepartment: Job Code: Hazards Which May Be
EncounteredInjuryMethods To Prevent InjuriesLifting
Objects/PatientsBack InjuriesHerniasUnderstand A&P of back,
causes of back pain, preventive approaches, use of aids when
lifting.Preventive measures when lifting and use aids when
lifting.Slip/Trip/FallsContusions, Sprains, StrainsAvoid undue
speed. Use handrails. Clean up spills immediately.Fires & Natural
DisastersBurns & All Types of InjuriesRecognize possible causes of
fires. Smoking materials, faulty equipment. Employees should
educate patients. Compressed gasses are flammable & under pressure
so must be handled with care. Workers need to be familiar with
disaster plans and know exit routes.Electrical HazardsShocks &
BurnsBe aware of unsafe equipment and appliances. Attend electrical
safety classes and seek assistance if any unsafe areas are
noted.AssaultsMinor Injury to DeathEmployees need to be cognizant
to potential dangers to ensure safety. Awareness of existing
security measures and defensive behavior can protect employee from
assaults.Needles & SharpsCuts, Punctures, LacerationsSharps should
be discarded in designated containers. Employees should exam &
handle soiled linens & similar items as if they contained hazardous
items.Obstacles & Broken ObjectsAbrasions, Contusions, and
LacerationsArrange furniture to allow free movement about the room.
Keep doors & drawers closed when not in use. Clean/discard broken
objects properly (i.e. broken glass should be swept up - not picked
up with fingers).Possible Exposures to Infections
Hepatitis/Tuberculosis/Cytomegalovirus/Varicella/AIDS/Herpes/Staph
Infections, Lice/Scabies/RubeolaInfectionUse Infection Control
procedures as defined in Infection Control manual. These include
handwashing, protective clothing, knowing the risks. Label linens
and wastes properly.Possible exposure to acids & other chemicals
used within the hospitalRefer to MSDS'sEmployees should follow
procedures as explained in their department Hazardous Material
training and refer to MSDS's before using/handling any chemical.
Follow procedures and do not use any chemical without proper
labeling.Hazards Which May Be EncounteredInjuryMethods To Prevent
InjuriesLatexDermatitis to deathAlert supervisor if you feel that
you are allergic to latex materials. Use non-latex gloves for
sterile procedures.Soaps, Detergents, Cleaning
SolutionsDermatitisFollow Departmental procedures. Protective
clothing is available if Dept. is unable to substitute agents that
do not cause dermatitis.Ergonomic ProblemsWide Variety of
Musculoskeletal nervous disordersBody mechanics, positioning of
equipment/furniture, and repetitive actions can cause employees to
experience a variety of physical problems. Employees should follow
safe body mechanics as described in hospital education. Employees
are encouraged to seek assistance from their supervisor if they
feel a task is causing them to experience physical problems. Work
site evaluation may be indicated and this should be discussed with
manager.Possible Chemical ExposureRefer to MSDS'sEmployees work
with a variety of chemicals within the lab setting. Employees
receive training upon hire and also are expected to review the
Chemical Safety Plan yearly. Employees are expected to follow safe
working procedures as instructed.Possible exposure to
radiationSterility, Cancer, Shortened Life ExpectancyWhen
appropriate, employees should wear film badges (they are monitored
routinely) and use lead aprons, gloves, or shields. Identify and
appropriately manage radiation therapy patients and their
secretions.Possible Exposure to Chemotherapeutic AgentsRefer to
MSDS'sEmployees involved in preparation or administration of
chemotherapy drugs have potential for exposure. Employees must
undergo training in their department and should follow procedures
as directed.Exposure to Video Display TerminalsEye strain & stress
in addition to ergonomic complaintsIt is unknown if significant
visual dysfunction results from long-term use of VDT's. Problems
may be controlled with control of lighting and glare, the color
contrast, and workers should have adequately corrected vision.
Employees should seek assistance from their supervisor if they feel
VDT is causing problems for them.1Job Description/Denials and
Appeals Coordinator- 2/21/22
Keywords: Washington Hospital Healthcare System, Fremont , Denials and Appeals Coordinator, Other , Fremont, California
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