Under general guidance of Patient Access Services Denial Manager, the Admitting Department Appeals Specialist is responsible for assisting with insurance denials and is expected to adhere to programs, policies and procedures to maximize reimbursement by minimizing denials. Under the supervision of the Patient Access Manager, the Appeals Specialist also monitors Huron and EPIC reports and work queues to ensure timely response to denied cases, prepares and submits appeals, provides follow-up on cases until resolution has been achieved. Reviews appealed cases to assist in the determination of departmental write offs, as appropriate. Cultivates, maintains and enhances relationships with third party payors. The analyst performs all these functions in a manner that complies with standards established by Hospital Administration, Medical Staff and outside regulatory and accreditation agencies.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
OPERATIONS MANAGEMENT
Works toward goals and objectives for departmental denial management.
Has a sound understanding of the payer rules related to the denials and appeals.
Communicates directly with payers, , Payor Operations, BWF and BWH Case Management, Admitting, Revenue Operations, Central Billing Office and other appropriate hospital and physician staff to coordinate appeal activity if deemed necessary.
Cultivates, maintains and enhances relationships with third party payors.
Provides case follow-up on denials until resolution has been achieved.
Formulates and submits timely, well prepared appeals with supporting clinical information and required data and provides this information to third party administrators (payers).
Assists in the determination of write offs and analysis provided to the Executive Director for review and approval.
Reviews Huron and EPIC reporting and documentation to determine the root causes for denials and works to implement action plans to prevent future denials.
Maintains clear channels of communication for effective problem-solving, as related to denials and troubleshoots routine and non-routine problems and takes appropriate actions to address issues.
Contributes to team work within and between departments. Attends and participates in related meetings as needed. Provides constructive ideas and suggestions in a positive manner.
Works collaboratively with co-workers and management to effectively resolve issues that impact departmental or hospital operations in order to increase reimbursement and minimize denials.
Performs various administrative functions, including, but not limited to, supporting management of payer contractions and contract operations around denials including compiling and summarizing denial data and trends in Excel and Word to support meetings and events.
PROGRAM MANAGEMENT
Assists in the design and implementation of programs to monitor denial and reduce denials.
Assists in the implementation of Quality Assurance programs targeting as goals not only accuracy and efficiency, but also high levels of patient and physician satisfaction.
COMPUTER SYSTEM MANAGEMENT
Assists in the development of functional specifications/requirements for computer systems, new computer programs and enhancements to existing systems.
In conjunction with Information Systems, Care Coordination and the Finance Department, assists in design, creation and verification EPIC and Huron Reporting and dashboards.
Assures accuracy and completeness of data collected by Patient Access Services and submitted to third party payors.
Works with Information Systems regarding system maintenance, enhancements and/or upgrades.
Develops manual procedures to handle computer downtime and crash recovery.
PERSONNEL MANAGEMENT
Creates an environment that encourages productivity, loyalty, job satisfaction, and a positive attitude.
Adheres to the hospital's personnel policies and procedures.
FISCAL MANAGEMENT
Assists management with analysis related to operating and capital budgets.
Generates and implements new ideas for reducing costs.
MISCELLANEOUS
Actively participates in designated special projects as needed.
Maintains ongoing knowledge of legislative and regulatory changes which impact hospital access to care and quality of care.
Qualifications
EDUCATION
High School diploma/GED required.
Bachelor degree in business, accounting or health care related field preferred.
EXPERIENCE
Minimum of 2-4 years in a health care setting with administrative and financial work experience
Denials or appeals experience required
SKILLS/ ABILITIES/ COMPETENCIES REQUIRED:
Requires effective, results-oriented skills.
Requires interpersonal skills to interact effectively with all levels of staff, management and leadership. Must be able to collaborate in an effective interdisciplinary team approach.
Requires superior problem-solving skills and the ability to work with multiple demands and priorities.
Requires independent judgment needed to deviate from standard policies, procedures and schedule when necessary.
Requires excellent communication skills both oral and written.
Requires sound analytical skills.
Requires knowledge of computers and management information systems and the ability to provide specifications for program development, system enhancements and reports.
Requires strong computer skills and understanding to efficient data mine denial data and presentation skills (e.g. Excel, Word), Powerpoint)
WORKING CONDITIONS:
Due to the volume of denials, and complexity in analysis, the pace of work is hectic and challenging, the workload could necessitate working off hours.
Must be able to adapt to changes in work space
Ability to work well in a demanding and changing environment
SUPERVISORY RESPONSIBILITY:
Assist with training of new employees when necessary.
FISCAL RESPONSIBILITY:
The key to the institution's financial viability lies in the integrity of data collected. The work performed by the Admitting Appeals Specialist is a cornerstone of the institution's reimbursement. This position plays a crucial role in preventing denials through root cause analysis and writing appeal as well assisting with retro-authorizations and analysis.
EEO Statement
BWH is an Affirmative Action Employer. By embracing diverse skills, perspectives, and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.
