Denials and Appeals Coordinator - Case Management - Per Diem - Days

Case Management / Social Work Fremont, California

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Description

Salary Range: $85.87 - $115.94 + applicable differentials 
 
Reporting to the Director of Case Management, with the support and direction of the Physician Advisor and 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 Washington Health.  Accepts projects as assigned. In addition to performing the essential functions, may also be assigned other duties as required.
 
Essential Responsibilities:
  1. Coordinates all clinical denial management activities to successfully appeal and recoup payments to the organization.
  2. 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.
  3. 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.
  4. Responsible for concurrent denials working with the physician advisor for denial prevention. 
  5. Assists with Epic Work Queues to resolve issues timely 
  6. Evaluates denials to determine root cause and implement activities to avoid denials from occurring and trend to ensure compliance 
  7. 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 
  8. Documents all activities in individual patient accounts using comments, reminders, and smart phrase functionality.  Tracks ongoing financial returns resulting from appeals activity. Writes and updates detailed procedures on all processes maintaining accuracy, integrity, and completeness
Job Competency includes:
  1. Expert in MCG and assist in the education of case managers, when requested 
  2. Maintains an understanding of the Patient Access System and Patient Accounting in order to identify internal issues that could cause a denial 
  3. Maintains an understanding of payor reimbursement to third party payors and governmental agencies such as Medicare, MediCal and Tricare 
  4. Maintains an understanding of all Managed Care Agreement and the contracted rates  
  5. Distributes up to date information and changes from payors to case management staff 
  6. Applies understanding of payor reimbursement and contracted terms/rates to identify incorrectly paid or denied claims that require an appeal to be done.
 
Qualifications Include:
  • California Registered Nurse License
  • Bachelor of Science in Nursing
  • 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 programs



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