The primary purpose of the Denials Prevention Analyst position is to identify and understand the causes of denials in order to mitigate denial risk for both acute and ambulatory claims. Through data analysis on clinical and technical denials, the analyst will apply high level problem-solving skills to identify the root cause and prioritize denial reduction initiatives. The creation of reports and dashboards will be used to identify trends and share information with impacted areas, stakeholders, and executive level. Understanding that the path to denials can start at any point throughout the revenue cycle, the Denials Prevention Analyst must work collaboratively with all points, including but not limited to, scheduling, patient access, clinical areas, managed care, HIS, charge capture, coding, billing, and collections. Partnering with areas where opportunities for improvement have been identified, the Denials Prevention Analyst will help develop and assist with the implementation of effective, preventative, and sustainable measures to correct the underlying issues impacting denials. The Analyst will create training and reference materials related to prevention and will educate areas impacted as necessary.
JOB DUTIES/RESPONSIBILITIES
Duty 1: Performs root cause analysis. Performs a deep dive analysis of denied accounts to identify root causes. Identifies high dollar and/or high-volume denials for the greatest impact and focus. Interprets data, reviews findings, and draws conclusions on ways to achieve denial reduction. Collaborates with Revenue Integrity Analysts in their efforts of process improvement.
Duty 2: Identifies trends or patterns that impact payment optimization and collaborates internally and with external departments, such as billing, coding, patient access, and utilization review, to establish initiatives to decrease denials system wide to optimize revenue.
Duty 3: Review, approve, and post adjustments based upon the Denial Write-Off Approval Levels. Use the adjustment tracker to identify any opportunities in trends and provide feedback and education to adjustment tracker users.
Duty 4: Establishes and monitors key performance indicators. Develops standardized reporting. Creates and presents denial reports/summaries and dashboards to provide denial related activity to leadership, stakeholders, and clinical departments that is meaningful to the end user.
Duty 5: Reviews denial appeal practices to evaluate for opportunities and educate to the best practice for responding to denials, focusing on ensuring the inclusion of all necessary documentation, meeting NCD, LCD, and payer policy guidelines for coverage. Provide feedback on ensuing a complete initial appeal to reduce the likelihood of a subsequent denial. Utilize quality audits to identify trends for education and training.
Duty 6: Facilitates the Avoidable Write-Off Committee. Focuses on denial prevention activities and performance improvement. Monitors next steps to ensure the continued efforts in denial prevention. Communicates findings through the Revenue Integrity Compliance Committee.
Duty 7: Compiles monthly reports/dashboards focusing on avoidable write-offs to identify any spikes or positive impacts of new process implementation. Monitors key performance indicators to track performance improvement activities and recognize important trends. Reports findings to the Revenue Integrity Compliance Committee.
Duty 8: Partners with Payment Integrity Analysts to ensure proper adherence to contracts and regularly communicates with the managed care team and Revenue Integrity Analyst regarding updates and changes to billing guidelines and payment policies. Track and communicate denials that do not adhere to contract or payer policy language.
Duty 9: Works with internal and external departments to identify and track areas of revenue leakage including opportunities for submitting corrected claims to capture lost reimbursement. Submits corrected claims and tracks for additional payment through completion of the claim. Reports monthly metrics for revenue capture of corrected claims.
Duty 10: Work closely with external vendors (Cloudmed, Forvis, etc.) to research and resolve identified issues which negatively impact the expected reimbursement. Assist in the implementation, testing, and training on new support tools.
Duty 11: Collaborates with Denials Management Team to provide detailed information to successfully resolve denials through the construction of a comprehensive appeal. Creates material to educate/train on process and procedure improvements that have been identified to have an impact on denial reduction.
Duty 12: Demonstrate superior understanding of federal, state and third-party charging guidelines. Analyze revisions to coding and billing regulations, including OPPS and IPPS as appropriate revisions, by resourcing credible references (i.e. CMS website, Craneware, publications, professional contacts, reliable internet sources, seminars, etc.).
Duty 13: Assists in developing revenue integrity-related departmental, division and/or organizational policies and procedures for recommendation and approval, as necessary.
Duty 14: Regularly attends and actively participates in in-services, organizational meeting. Utilize lean management tools (e.g. huddles, idea boards, A-3 process, mapping, etc.) and continuing education programs as offered in order to remain current with organizational and industry changes and best practice. Communicate and disseminate information to other departments as applicable.
REQUIRED QUALIFICATIONS
An associate degree in a related field including, but not limited to, health information, business, healthcare finance or related clinical profession required or 5+ years' experience from which comparable knowledge and abilities have been acquired.
Three (3)+ years denial experience working with commercial and government payer types for both professional and facility claims.
CCS, CCS-P or CPC certification required within 6 months of hire.
CPFSS certification within 12 months of hire.
Regulatory, compliance, and reimbursement methodologies knowledge required. Ability to research, review, analyze, and interpret Federal, State and Local billing regulations required.
Demonstrated ability to navigate through commercial and government agency payer websites, to research and understand billing requirements, instruction, and payer guidelines.
Ability to effectively present data and complex information in an informative and meaningful way to a variety of audiences, including leadership.
Ability to effectively educate all levels of the organization with small and large audiences (e.g. coders, clinical departments, medical staff, executive staff, etc.)
Ability to manage complex issues and manage multiple tasks/projects. Excellent organizational and time management skills; detail oriented and follow through. Self-directed.
Excellent computer skills and the ability to create reports, dashboards, and presentations using Word, PowerPoint, moderate-advanced skills in Excel required, and other office products.
Strong interpersonal skills, critical thinking skills, and communication skills
Strong problem-solving, research and analytical skills required.
CPT/APC/HCPCS and ICD/DRG coding and reimbursement concepts knowledge required.
Positive service-oriented interpersonal and communication (written and verbal) skills required. Ability to effectively present and interact with all levels of the organization, including senior leadership.
This position requires a full range of body motion with intermittent activities in walking, lifting, bending, squatting, climbing, kneeling, and twisting. The associate will be required to sit for five hours a day. The individual must be able to lift ten to twenty pounds and reach work above the shoulders. This position requires corrected vision and hearing in the normal range. The individual must have excellent eye-hand coordination and verbal communication skills to perform daily tasks.
