Denials Management Coordinator

Description

Location: Main Campus

Department: SPN - SCHEDULNG

Schedule: , 8 HR Day Shift, 8

Position Summary

The Denials Management Coordinator is responsible for thorough understanding of existing and future managed care payment methodologies. They must effectively analyze zero paid, underpaid, overpaid and denied insurance claims and make recommendations for continued revenue growth. The coordinator is responsible for: timely and accurately, interpreting all payer contracts and regulations to determine the correct payer and reviewing denied, bundled, and underpaid line items. Responsible for determining the optimal combination of rebilling, collections, and follow-up activities to ensure correct reimbursement. This includes coordination with payers, Patient Financial Services, Patient Access Services, Finance, Accounting, SGMC Physician Network and other departments as necessary. This position is responsible for timely and accurately reviewing and trending all payer contractual adjustment variances.

Among other duties, this individual is responsible for coordinating specialist’s efforts to resolve complex accounts and ensuring specialist’s and scheduler’s interactions with patients are consistent and compassionate during billing, scheduling, and follow-up activities. Working all necessary work queues and maintaining required threshold. The Denials Management Supervisor helps to monitor all self-pay and third-party collection activities for the physician group and its affiliates and serves as a day-to-day resource for specialists and schedulers. Establishes work schedules, assigns duties, provides instructions, and ensures staff maintain appropriate workloads and productivity. Ensures staff are actively and appropriately communicating with payers regarding delayed, denied, and underpaid claims. Also ensures staff are actively and appropriately communicating with patients and offices appropriately. Assists staff when accounts are challenging, problematic, and/or unresponsive as necessary; escalates critical or ongoing issues to Authorization/Scheduling Manager.

EDUCATION

• High School Diploma or GED Equivalent.
• CPAR preferred.
  
  

EXPERIENCE

• Extensive knowledge of insurance/managed care, to include: Medicare; Medicaid (Georgia and Florida); Medicaid CMO’s, Peach Care; Tricare (Standard, Extra and Prime); VA; Medicare Managed Care; Blue Cross (Georgia, Florida, out-of-state and FEP).
• 3 year working experience in healthcare billing, authorization, or insurance verification.
  
  

KNOWLEDGE, SKILLS, AND ABILITIES

• Technical/system skills/knowledge: PC and Windows literacy required; prefer knowledge of, or experience with, EPIC and Microsoft Office applications.
• Extensive knowledge of insurance/managed care, to include: Medicare; Medicaid (Georgia and Florida); Medicaid CMO’s, Peach Care; Tricare (Standard, Extra and Prime); VA; Medicare Managed Care; Blue Cross (Georgia, Florida, out-of-state and FEP).
• Working knowledge of CPT-4, HCPCS, ICD-10, and DRG coding.
• Reimbursement methodologies: percent of charges; DRGs; discounted fee-for-service; fee schedule; cost-based; and per Diems.
• Must have a thorough understanding and knowledge of: patient type; financial class; insurance master; employer codes; admission source codes; relationship codes; accommodation, occurrence, value and condition codes.
• Related regulatory and legal requirements: Medicare Secondary Payer Questions; medical necessity; Medical Reviews and Appeals.
• Interacts with: patients; other departments; physician offices; acute medical care providers; insurance companies; employers; Medicare administrative contractors; utilization review companies; state regulatory agencies, GMCF, Medicaid.
• Knowledge of medical terminology.
• Strong verbal/written communication skills.
• Highly organized with the ability to prioritize work.
• Types 80 wpm accurately.
• Clinical background beneficial.
  
  

WORKING CONDITIONS - ADA INFORMATION

Generally regular work schedule during normal office hours. Comfortable setting indoors. May be subjected to high levels of stress. Must be able to sit for prolonged periods of time. Moderate heavy lifting (0-25 lbs.), reaching, stooping, pushing, pulling, bending and twisting. Must be able to operate office equipment to include FAX, copier, and computer.