Denials Specialist TC

Brown Medicine•Cranston, RI

7d•$23 - $38•Hybrid

About The Position

Under general direction and within established Brown University Health policies and procedures, the Denials Specialist maximizes reimbursement from contracted payers by analyzing, tracking, and trending denials using available metric denial reports. The role supports strategic initiatives, process redesign, root cause analysis, metric and report development, and special projects related to denials management. It also executes the appeals process by receiving, assessing, documenting, tracking, analyzing, responding to, and resolving appeals with third-party payers. The position evaluates denied accounts, routes them to appropriate work queues, identifies recurring issues and potential preventative solutions, monitors timely follow-up, and reviews denial data to identify root causes and trends. The specialist collaborates with hospital departments, referring physician offices, affiliate departments, and payers to obtain information and resolve denials and appeals. The role maintains knowledge of applicable regulations, accreditation and compliance requirements, organizational policies, payer policies, and payer contracts; researches payment and processing issues; tracks appeals against established timelines; and performs related account adjustments and reporting. After orientation at corporate facilities, work may be performed in the office, in a dedicated home workspace, or through a combination of the two, subject to management approval and applicable telecommuting policies. The schedule is Monday through Friday, 8 a.m. to noon, for four hours daily. Staff must attend scheduled meetings, remain available during scheduled hours, and stay signed into Microsoft Teams throughout their shift.

Requirements

Associate’s degree in accounting, business office practices, computer science, or a related area, or equivalent experience.
Three to five years of experience in hospital patient accounting.
Experience demonstrating thorough knowledge of claims administration in a similarly complex healthcare organization.
Familiarity with ICD-9/10, CPT-4 coding, UB04, and HCFA 1500 claims administration.
Ability to perform financial analysis.
Comprehensive knowledge of patient accounting activities in an automated, networked, multiple-hospital environment.
Detailed knowledge of regulatory requirements.
Ability to work independently within department policies and practices, referring specific problems to a supervisor when clarification of policies or procedures is needed.
Ability to participate in scheduled meetings and remain available to management throughout scheduled hours; staff must remain signed into Microsoft Teams during the entire shift.
No supervisory responsibilities.

Responsibilities

Evaluate denied accounts referred to the Denials Management Department and assign them to appropriate department work queues for resolution.
Identify repetitive denial issues and potential preventative solutions; monitor work queues or reports for accounts not addressed promptly and follow up with departments.
Review denial database entries, categorize provider-liable denials, identify root causes and resolutions, and conduct month-end reviews to report trends, emerging issues, and opportunities.
Respond to departmental questions or concerns about monthly denial-report data.
Build and maintain working relationships with hospital departments and referring physician offices to obtain information needed for successful appeals or denial reversals.
Maintain current knowledge of state and federal regulations, accreditation and compliance requirements, Brown University Health policies, payer policies (including LCDs and NCDs), and payer contracts to identify denial causes.
Research payer issues involving payment delays, denials, underpayments, and processing deficiencies, and recommend changes as appropriate.
Review monthly payer updates and prepare a report for presentation at the monthly Appeal/Denial meeting.
Track appeals and maintain organized records to ensure established timelines are met.
Maintain working relationships with payers to help ensure claims and appeals are processed appropriately.
Process LifeChart online adjustments or changes related to appeals, as needed and within the scope of the role.
Evaluate workflows and identify opportunities to improve processes and obtain complete payment for hospital services.
Create, generate, and maintain ad hoc reports requested by the Manager to support daily departmental operations.
Participate in staff meetings, councils, quality-improvement teams, and other required meetings and committees.
Maintain working relationships with Brown University Health affiliate departments as needed to support complete data exchange.
Perform other duties as necessary.
Follow the Brown University Health Corporate Compliance Program and Code of Conduct and model the organization's values and Success Factors.