Clinical Denials and Appeals Team Lead

AGS Health Philippines, Inc; Manila; Sur place; PHP 900 000 - 1 300 000; Plein temps

Résumé du poste

AGS Health Philippines, Inc. seeks a Team Leader - Clinical Services to guide denials and appeals with expert medical coding oversight in a dynamic BPO setting.

You will supervise a team, drive SLAs, and coordinate with SAP, HR, IT, Finance, and client teams to ensure optimal reimbursement and service quality. RN certification and strong coding knowledge are essential for success.

Qualifications

• Registered Nurse (RN) certification required.
• Proficient in inpatient/outpatient coding terminology and guidelines (DRG, ICD-10).
• Experience with MCG and InterQual criteria.
• Experience leading a Clinical Denials and Appeals team.
• Experience in medical billing, coding, or utilization review; writing insurance appeals or handling denials.

Responsabilités

• Monitor and improve SLAs for cash collection, production, quality, and TAT.
• Supervise team strategies to meet or exceed SLAs.
• Improve operational systems, processes, and policies supporting client SLAs.
• Replicate best practices to improve management quality.
• Contribute to short- and long-term organizational planning and strategy.
• Oversee process costing and profitability with related departments.
• Coordinate with SAP, HR, IT, Finance, and Employee Engagement.
• Coach supervisors and assistant managers in required skill sets.
• Participate in client communications via email and phone with CSMs.
• Ensure adherence to client and organizational policies.
• Pursue continuous process improvement through innovation.
• Review inpatient/outpatient medical necessity denials for validity.
• Review denial and account for reimbursement actions.
• Apply payer policies, MCG, InterQual criteria to determine appeals.
• Write payer appeal letters citing clinical indicators and guidelines.
• Analyze medical records and EOBs to identify root causes of denials.
• Document in EMR and assemble appeal packages.
• Manage accounts until payment, write-off, or adjudication.
• Report quality results and provide educational support and training.

Connaissances

Medical coding terminology

DRG & ICD-10 coding

MCG & InterQual criteria

Denials & appeals handling

Medical billing & utilization review

Insurance appeals writing

Formation

RN certification

Description du poste

QUALIFICATIONS

• Registered Nurse (RN) certification.
• Proficiency in medical inpatient and outpatient coding terminology and guidelines, including but not limited to DRG, Diagnosis, CC, MCC, ICD-10 Coding
• Hands-on experience with MCG and InterQual criteria.
• Previous experience handling a Clinical Denials and Appeals Team
• Prio experience in: Medical billing, coding, or utilization review (preferred). Writing insurance appeals or handling claim denials (plus).

RESPONSIBILITIES

The main responsibilities of a Team Leader - Clinical Services include:

Team Management

• Continually monitor and improve overall SLAs (Cash Collection, Production, Quality, TAT)
• Supervise team-wise strategies, which will be used to meet or exceed SLAs
• Improve the operational systems, processes, and policies in support of the client’s SLAs
• Replicate best practices within the industry to ensure better management qualities
• Contribute to short and long-term organizational planning and strategy
• Oversee financial management of the processes and work with respective departments in terms of costing and profitability
• Ensure effective and timely coordination and communication with the support functions (SAP, HR, IT, Finance, Employee Engagement).
• Supervise and build a good next-in-line coaching of supervisors and assistant managers based on the required skill sets.
• Be an active participant of all client communication via email and phone and provide adequate support to the CSMs (Client Service Manager)
• Comply with the client and organization’s internal policies and procedures
• Be on the lookout for continuous process improvement through innovation and technical intervention

Process Handling

• Effectively review inpatient and/or outpatient medical necessity and authorization denials to determine and understand the validity of such denials in a timely manner.
• Conduct comprehensive reviews of the claim denial and account to determine what action should be taken to obtain reimbursement.
• Utilize payer policies, MCG, and InterQual criteria to determine if the account meets criteria for appeal.
• Write an appeal letter to the payer using appropriate clinical indicators, citing Official Coding Guidelines, and documentation from within the patient's medical record. Validate billing accuracy: UB, PB invoices, EOB, CPT/HCPCS codes.
• Ability to analyze medical records and Explanation of Benefits (EOB) to accurately identify the root cause of claim denials.
• Perform all other necessary steps on the specified accounts per Clients SOPs, including documentation in the EMR and appeal package creation.
• Manage the accounts until payment is received, the account is written off, transferred to patient liability, or other adjudication/movement within the system that is appropriate and agreed upon by both parties.
• Report quality results, track and trend educational opportunities for the coding and CDI specialists, respond to client subject matter needs, and provide educational support and training.