Mgr Appeals & Denials

Wellstar Health System

8d

About The Position

Under the direction of the Director of HB A/R Management, the Manager RC of Denials and Appeals coordinates all assigned HB Denials and technical appeals department activities including, but not limited to supervising, training, interviewing, hiring, counseling and terminating employees, as circumstances dictate. The Manager of Denials and Appeals must provide the dynamic development of strategies for establishing a continuous improvement work environment, open and closed technical denial accounts are reviewed, corrected, escalated, or closed within the designated payer time frames and are documented appropriately in the patient accounting system. The role requires extensive data analysis, trending analysis, project management, and departmental educational capabilities regarding payor and revenue cycle payment related processes. This role requires a versatile and well developed knowledge of billing, collections, technical denials appeal/correction process, and understanding of provider/payor escalation requirements. In addition to a strong understanding and capability of common business technologies such as MS Office, Excel, PowerPoint, Word and Outlook to perform and communicate the assessment and analysis of multiple acute care and LTAC facility accounts receivable portfolios. The core role focus of this position is to ensure that open and closed technical denial accounts are brought final resolution through reimbursement for services and to mitigate financial losses through solid operational execution, development and conformity to defined Policies and Procedures. The Manager must possess the ability to develop and document action plans for quick resource deployment and communicate timely with staff to understand the specific reasons for on going open technical denial trends. The role requires the ability to effectively and efficiently communicate both orally and in writing to Senior Leadership, multi-task, meet deadlines, enforce organizational policies and procedures, maintain high staff engagement, ensure staff productivity, appropriate cost controls and produce effective operational execution. In addition, the Manager will assist with additional Revenue Cycle related tasks and duties as assigned.

Requirements

• Bachelors Business Administration/Management or Bachelors Health Administration or Bachelors Other Required Minimum Education:
• Minimum 5 years hospital healthcare preferred, claims processing management, collections or other management, or other management role in a healthcare environment Required
• Establish a climate to achieve optimal performance levels and maintain a cohesive work team.
• Demonstrate proficiency in reading UB04.
• Demonstrate knowledge and proficiency Payor Appeal submission (technical).
• Demonstrate knowledge of billing rules and coverage for all major payors.
• Identify where to locate and review state and federal regulations as they relate to all payers.
• Access Major payer(s) specific provider websites for claim investigation, correction and resolution path determination.
• Identify technical denial trends effecting the revenue cycle and escalate for needed solution.
• Analyze all technical denials effecting the revenue cycle.
• Create and studies revenue reports/Key Performance Indicators and makes recommendations relative to revenue cycle processes for optimization.
• Follow standard escalation process in established time frames.
• Demonstrate knowledge and proficiency of claims resolution.
• Review staff productivity report on a weekly basis and identify areas of opportunity.
• Post adjustments at time of account review.
• Create/update department policies and procedures.
• Access Major payer(s) specific provider websites for claim investigation, correction and resolution path determination.
• Work efficiently under pressure and deal effectively with constant change.
• Operate a computer and related applications.
• Apply appropriate supervisory, management and leadership techniques in an operational setting.
• Work independently and take initiative.
• Demonstrate a commitment to continuous learning.
• Willingly accept responsibility and/or delegate responsibility.

Responsibilities

• Ensures staff follow-up on technical denial claims promptly, and is held accountable for aged receivables.
• Conducts regularly scheduled staff meetings to discuss new or modified procedures within department.
• Works with Account Follow up Managers to maintain a leading practice appeals toolkit, which includes template letters organized by type of denial to facilitate hand-off.
• Ensures staff maintain electronic and/or hardcopy folders of all appeals filed and all associated documentation used for each appeal to serve as a historical audit repository and for tracking/trending purposes.
• Reviews and approves staffs time and attendance records.
• Plans work schedules and assigns work to staff to ensure adequate service and coverage.
• Ensures Wellstars policies and procedures are current, and updates them as necessary.
• Approves technical denial and administrative write-offs in accordance with the Wellstars Adjustment Approval Policy, and audits staff level write-offs to ensure appropriateness.
• Addresses/resolves issues relating to patient accounts.
• Assumes responsibility for resolving inter/intradepartmental issues quickly and effectively.
• Analyzes technical denials reports to identify technical denial trends and issues, communicates issues regularly with Revenue Cycle Analysts, and understands how denied charges are impacting the overall accounts receivable.
• Identifies root cause issues relating to technical denials and communicates these issues to the Denials Management & Cash Posting Manager and/or Revenue Cycle Analysts for upstream education.
• Provide assistance with departmental projects and presentations, as needed.
• Maintain and reflect a positive team attitude, regarding any special projects or polices that are implemented by the Revenue Cycle or other senior leadership.
• Review, analyze, and interpret monthly management reports to make informed managerial decisions to increase productivity or resolve issues. In addition, must communicate recommendations or findings to Revenue Cycle Directors
• Maintain professional conduct and good working relationships with co-workers, supervisors, and staff
• Maintain a system to informally and formally recognize staff for accomplishments
• Demonstrate a thorough understanding of all state and federal regulatory requirements for government and third-party agencies to ensure compliance and appropriate reimbursement.
• Maintain standards in the use of claims management and denial management software, and all other software applications that are used in Physician Billing and Follow Up for consistency in account management
• Develop and maintain positive working relationships with third party payers to facilitate the resolution of issues and expedition of payments
• Oversee and ensure the completion of all employee paperwork and files, including the accurate and timely completion of timecards, employee evaluations, leaves of absence, workers compensation reporting forms, and employee education files
• Communicate and participate in regular meetings with contracted and non-contracted payers to identify, present, monitor, and resolve operational issues related to new medical policy, products, disputed payments, and/or system-related issues
• Identify and bring to management attention any opportunities for system or process improvements
• Assist in the development of criteria-based performance evaluations and staff job descriptions
• Approve and oversee the tracking of all employees sick and/or vacation requests in accordance with department policy and staffing requirements Must actively participate and support the efforts of the Revenue Cycle Task Force, as well as other committees as assigned.
• Maintain ongoing communication with other Revenue Cycle departments, keeping the Director aware of more complex problems and opportunities while maintaining courteous, cooperative, flexible and positive working relationships with all levels of management, employees, physicians, guests and the general public.
• Maintain a working knowledge of relevant legal and compliance issues, including but not limited to HIPAA privacy, Fair Debt & Collection Act guidelines, Medicare & Medicaid regulations, as well as state and federal laws.
• Maintain effective communications with legal collection groups, the WellStar Compliance department and other agencies, regarding new and relevant issues must maintain appropriate knowledge and skill sets to read and interpret various regulatory requirements that affect technical appeals and denials functions. Maintain appropriate documentation to assure an audit trail of compliance-related activities.
• Communicate with and obtain assistance from various type insurance, third party collection, governmental and regulatory agency representatives, in the interpretation of critical regulations and the collection/resolution of patient accounts.
• Performs other duties as assigned Complies with all WellStar Health System policies, standards of work, and code of conduct.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Number of Employees: 1-10 employees