Denials Analyst

Eisenhower Medical Center; United States; On-site; USD 30,000 - 46,000; Full time

Job summary

Eisenhower Health seeks a Denials Analytics Specialist to research and resolve claim denials, process ADRs, and track appeals. You will work with revenue cycle teams to improve workflows, respond to audits, and maintain payer reference materials for pre-authorization and medical necessity requirements.

Required: high school diploma or GED, 3 years of hospital billing experience focused on denials and appeals; preferred: associate degree and coding program enrollment.

Qualifications

• High school diploma required; preferred associate degree.
• Three years hospital or professional billing experience in denials follow-up.
• Strong knowledge of CMS rules, CPT/HCPCS/ICD-10 coding.

Responsibilities

• Research and resolve claim denials and ADR requests.
• Submit and track appeals; monitor payer requirements.
• Identify denials trends and produce monthly reports.
• Respond to audit requests and maintain payer reference materials.
• Maintain HIPAA compliance and protect patient information.
• Collaborate with Revenue Cycle stakeholders to improve processes.
• Create and submit strong concise payer appeals for revenue recovery.

Skills

Denials analytics

Analytical skills

Attention to detail

MS Office Suite

HIPAA knowledge

Education

High school diploma or GED

Associate's degree (preferred)

Tools

Epic EHR

Microsoft Office Suite

Job description

Default Work Shift: Day (United States of America) Hours: 40 Salary range: $21.75 - $33.04 Schedule: Full Time Shift Hours: 8 Hour employee Department: Denials Analytics Job Objective: Researches and resolves claim denials, ADR requests and certs; submits and tracks appeals, notes trends and provides monthly reports. Responds to audit requests (including RAC) from payors and maintains a Library of Payer reference material regarding requirement for pre authorization, medical necessity and documentation requirements. Works with the Revenue Cycle stakeholders (e.g. Admitting, Coding, Provider Liaisons, etc.) to provide information related to denials and opportunities for process improvement.

Job Description: Education: Required: High school diploma, GED or higher level degree Preferred: Associate's degree Licensure/Certification: Preferred: Certified coder or currently enrolled in a coding program Experience: Required: Three (3) years of hospital/professional billing experience with an emphasis in denied claims follow-up, appeals processing, managed care and/or Medicare/Medi-Cal reimbursement methodologies Preferred: Patient accounting experience in a high-volume claims’ environment Reports To: Manager-Denials Analytics Supervises: N/A Ages of Patients: N/A Blood Borne Pathogens: Minimal/ No Potential Skills, Knowledge, Abilities: Ability to identify denial issues and craft succinct payer appeal letters, Ability to prioritize and coordinate workflow productivity with attention to detail, Basic knowledge of CMS coverage requirements and types of Medicare coverage (Part A/Part B/Part C, etc.), Knowledge of CPT, HCPCS and ICD-10 coding requirements with emphasis on modifiers and diagnosis association, Knowledge of health care pricing and reimbursement methodologies, especially IPPS/OPPS, Knowledge of health plan contracts, hospital revenue cycle functions and payor compliance, Knowledge of LCD’s, NCCI, MUE edits, Commercial, PPO, HMO, POS, EPO, and Medicare Advantage claims, authorization and documentation requirements, Proficient in Microsoft Office Suite (Word, Excel, Outlook, PowerPoint) and other relevant software applications, Strong analytical skills.

1. Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.
2. Manages denial inventory on a timely basis to promote payment and resolution of all accounts as instructed by management.
3. Stays current on all payer requirements by reading bulletins, reviewing provider handbooks, accessing websites, etc.
4. Participates and engages in training sessions to grow knowledge base pertaining to denials, revenue cycle, and/or payor trends.
5. Contacts payors, performs timely follow-up through direct phone calls, provider claims websites, correspondence, appeals, etc.
6. Performs manual calculations of expected reimbursement to validate payor adherence to contracts.
7. Performs in depth account research to understand every aspect of claims billing and resulting denial.
8. Creates and submits strong succinct appeals that result in revenue recovery for all types of denials including contract underpayments, payor error denials, etc.
9. Identifies patterns, trends, and root-cause for denials; reports findings to management to facilitate process improvement and resolution, including compilation of bulk denial issues across high volume of accounts.
10. Generates and creates reports in Epic as requested.
11. Adheres to HIPAA standards while performing denials research/resolution.
12. Performs other duties as assigned.

Welcome to Eisenhower Health Careers! Eisenhower has been a leader in health care for the Coachella Valley since we opened our medical center in 1971. Since then, we’ve been growing steadily, adding services, capabilities and facilities to anticipate and meet the needs of our expanding area. Today, the Eisenhower name extends far beyond the state-of-the-art care we deliver at the hospital.