Denials Specialist

Community Behavioral Health.•Philadelphia, PA

123d

About The Position

CBH is a dynamic organization dedicated to providing access to high-quality, accountable care to improve the health and mental wellness of our members. The mission of CBH Denials Specialist is to oversee all aspects of the denial process for Clinical Management and Medical Affairs. This includes daily review of all insufficient denial notices. The Denials Specialist will also participate in grievance hearings as the clinical representative.

Requirements

Education: Master’s degree in Social Work or related field
PA Child Abuse Clearance and Criminal Background Check required.
Excellent verbal and written communication skills and ability to use them when communicating with internal and external stakeholders
Excellent interpersonal and collaboration skills
Proficient in MS Office
Ability to work independently and as part of a team
Excellent time management and prioritization skills and ability to multi-task
Compliant with HIPAA regulations
Philadelphia Residency Requirement: The successful candidate must be a current Philadelphia resident or become a resident within six months of hire.
U.S. Authorization Requirement: CBH does not provide sponsorship for applicants requiring future work authorization. All candidates must be legally authorized to work in the United States without requiring sponsorship now or in the future.

Nice To Haves

Relevant Work Experience: Experience in a managed care setting preferred, as well as experience with regulatory agencies.

Responsibilities

Be knowledgeable about behavioral health care services, system partners, service continuum, and established medical necessity criteria.
Serve as the subject matter expert on all aspects of the denial process at CBH including policies, protocols, NCQA and HealthChoices regulations.
Update the annual Denial Training and ensure that all required staff have completed the training.
Serve as the clinical representative in all grievance hearings.
Review all insufficient and denial notices and ensure accuracy prior to their release.
Complete monthly timeliness and system control reports.
Review monthly denial audits and follow up when indicated.
Prepare all denial documents for NCQA review.
Maintain documentation in CBH’s electronic system consistent with agency and industry standards.
Respond to correspondence within 24 hours, or sooner if necessary.
Work collaboratively with team members including assisting with the training of newly hired employees as requested, covering work when peers are out of the office as assigned and finding coverage when absent.
Attend all meetings as assigned and actively prepare for and participate in supervision.
Assist with special projections and all other duties as assigned.