Clinical Denials & CDI Administrative Coordinator

Adventist Health • Roseville, CA

225d

About The Position

Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect. Whether virtual or on campus, Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work. Job Summary: Assists the clinical denials team & CDI team by coordinating the process of handling Inpatient denied claims from insurance payers/auditors, focusing on identifying the denied topics for clinical validation/DRG down grade, implementing corrective actions, and ensuring timely resolution to minimize financial losses. Supports the team's key processes by maintaining resource documents, spreadsheets and performing various tasks as delegated by the denial management CDI team by maintaining records and tracking appeals. Communicates and follows up with payers via email, Fax, electronic portal, paper mail and assisting with process improvements to optimize reimbursement and minimize denials.

Requirements

• High School Education/GED or equivalent: Preferred
• Associate's/Technical Degree or equivalent combination of education/related experience: Preferred
• Three years' experience within healthcare revenue cycle or other healthcare field performing any variety of organizational, administrative, or process improvement functions: Preferred
• Two years' of experience within healthcare revenue cycle or other healthcare field: Preferred
• Experience in healthcare billing/denial/coding experience: Required

Responsibilities

• Coordinates the appeal process for all AH facilities clinical.
• Acts as a resource for staff questions related to information workflow and timely filing.
• Escalates issues to management if deadlines are missed, payer responses are not received, or process gaps are identified.
• Assists with identifying and resolving system and payer issues that result in payment delays, incorrect payments.
• Collaborates and communicates regularly with contracted Health Plans, internal departments and any other teams when appropriate.
• Ensures all applicable department and regulatory targets for productivity and department performance process improvements in the area of denials are attained.
• Identifies, documents and reports incidents with missing information pertinent to payer denials.
• Provides helpful assistance in anticipating and responding to the needs of the clinical denial team.
• Uploads denial letters and enters case information obtained from the EOB/claim/denial letter into the Veracity software.
• Collaborates with coding, billing vendors, revenue integrity teams, and managers to ensure timely and accurate claim processing and denial resolution.
• Assists the clinical documentation integrity team in other (non-denial) administrative responsibilities, if needed.
• Tracks progress and outcomes of denial and appeal processes under the CDI denials team leadership.
• Works in a fast-paced environment, utilizing your skills to manage inpatient denials and ensure accurate reimbursement.
• Stays informed about the latest regulations and best practices in denial management to ensure compliance and optimize the denial process.
• Assists with monitoring authorization, notification, and clinical validation/DRG down grade denials and appeals submitted by the clinical denial team.
• Maintains an accurate list of how to submit appeals and appeal timeframes for various payers.
• Submits and tracks appeals until final resolution.
• Assists in reviewing contract language to determine whether the insurance company's reimbursement policy conflicts with Adventist Health contract with the payer.
• Performs intake of audit adjustment requests and assists with triaging adjustment requests and claim denials to ensure they are routed to the appropriate staff.
• Coordinates timely processing of all appeals at all levels.
• Submits appeals, assists with contacting payers for appeal status, monitors claim activity for appeal outcomes, and performs data entry related to appeal activities.
• Tracks the status of appeals, including deadlines and outcomes.
• Monitors and works denials report received from patient financial services (PFS) and maintains close working relationship with PFS.
• Assists with the preparation of appeal letters and supporting documentation.
• Follows up with payers to ensure timely responses and resolution of appeals.
• Serves as a point of contact for inquiries related to denials and appeals.
• Collaborates with the denial management team to ensure efficient and effective denial resolution.
• Performs other duties as assigned by the clinical denials team/CDI leadership.
• Identifies and reviews denials, redistributes appropriately to the correct team if needed.
• Performs high-volume printing, copying, and mailing of patient statements, appeals, and office packets.
• Performs other job-related duties as assigned.

What This Job Offers

• Industry: Ambulatory Health Care Services
• Education Level: High school or GED