Denials Resolution Specialist II

UMass Memorial Health•Worcester, MA

15h•Onsite

About The Position

Responsible for reviewing, analyzing and initiating appropriate action for complex denial resolution by communicating with payers, hospital departments and patients. At UMass Memorial Health, everyone is a caregiver – regardless of their title or responsibilities. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve. We are more than 20,000 employees, working together as one health system in a relentless pursuit of healing for our patients, community and each other. And everyone, in their own unique way, plays an important part, every day.

Requirements

A minimum of a High School diploma.
Four or more years of experience in health care billing functions.
Previous health care billing experience.
Proven track record of successful performance and goal achievement.
Experience in denial resolution process.
Advanced knowledge of claim form content and claim submission requirements. Understands and can explain the purpose of revenue codes, condition codes, occurrence codes, modifiers and value codes.
Proactively proposes resolutions to issues.
Ability to communicate verbally and clearly document all actions taken during resolution process.
Demonstrates ability to research denial issues. Can provide root cause of denial issue and identify next steps needed to resolve issue.
Ability to navigate in MassHealth claims processing application and/or the Medicare claims processing application.
Experience with high dollar- high complexity claim submissions, i.e. Long length of stay, coverage changes and lapse, coordination of benefit issues.
Ability to work collaboratively and effectively with people.
Exceptional communication and interpersonal skills.

Responsibilities

Triages denial root cause and executes appropriate next steps.
Identifies trends and participates in interdepartmental resolution strategies to reduce and eliminate future denials. Researches complex denials as assigned.
Trains staff on payer websites, providing basic guidance and instruction on website navigation.
Uses assigned work queues and prioritization standards and guidelines to perform denial resolution follow up. Work queues assigned will be representative of UMMHC more complex payers.
Resolves accounts denials with high dollar balances (>$100,00) recognizing the potential complexity and the need for rapid resolution.
Uses reference material to troubleshoot payer issues and increase understanding of denial resolution techniques. References payer websites as needed.
Analyzes and researches the denial reasons for each assigned denial code. Recognizes and differentiates between claim denials and payment variances. Initiates appropriate account follow up.
Participates in payer and internal audits. Supports requests for information, claim correction and/or resubmission. Maintains appropriate documentation related to original audit findings.
Corrects and updates claim information in the Medicare FISS system requiring in depth knowledge of Medicare billing and compliance regulations.
Correct and resubmit claims in Mass Health MMIS and other payer websites.
Completes appropriate actions needed for an effective appeal including conducting authorization research, rebilling, and balance write off or transfer to next responsible party. Escalates issues as appropriate.
Corresponds with third party payers, hospital departments, and patients to obtain information required for denial resolution following payer timelines. Releases information following Federal, State and Hospital guidelines.
Follows payers established procedures and timelines to submit appeals utilizing payers preferred method, i.e., electronically or via paper.
Documents all actions taken during the denial resolution process clearly including actions taken, next steps, payer processing timelines, etc.
Adjusts account balances using correct transaction while code adhering to guidelines.
Follows established protocols to ensure all documents are retained appropriately.
Meets established quality and productivity standards.
Facilitates and promotes the sharing of knowledge and content throughout departments.
Follows all established Hospital Billing Revenue Cycle Management departmental and compliance policies and procedures.
Adheres to change control processes.
Participates in cross training to optimize resources.
Demonstrates excellent attendance and actively participates in a variety of meetings and training sessions as required.
Maintains and fosters an organized, clean, and safe work environment.
Actively contributes to the development and application of process improvements.
Maintains a collaborative, team relationship with peers and colleagues in order to effectively contribute to the group’s achievement of goals and to help foster a positive work environment.
Demonstrates respect for the diversity of patient and employee populations. Supports and encourages diverse points of view, work, and lifestyles.
Practices cost containment and fiscal responsibility through the efficient use of supplies, equipment, time, etc.
Performs a variety of related duties as assigned by management.