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