Denials Analyst-Denials Analytics

Eisenhower Health; Rancho Mirage (CA); On-site; USD 62,322,624 - 94,672,804; Full time

Job summary

Eisenhower Health in Rancho Mirage, CA is seeking a Denials Analytics specialist to research and resolve claim denials, manage appeals, and track payer trends. The role collaborates with Revenue Cycle stakeholders to improve processes and denial outcomes.

Requires 3 years hospital billing experience and knowledge of CMS/Medicare; high school diploma is required, associate's degree preferred, and coder certification preferred. This is a full-time daytime role in a 40-hour work week.

Qualifications

• High school diploma or GED required; associate's degree preferred.
• Certified coder or active coding program enrollment preferred.
• Minimum three years hospital billing/denials experience required.

Responsibilities

• Manages denial inventory to promote timely payment and resolution.
• Responds to payer requests and audit inquiries (including RAC).
• Creates and submits strong payer appeals to recover revenue.
• Generates reports in Epic and analyzes denial trends for process improvement.
• HIPAA compliance is maintained while performing denials research and resolution.

Skills

Denials follow-up

Appeals writing

CMS requirements

Medicare/Medicaid knowledge

Microsoft Office

Education

High school diploma or GED

Associate's degree (preferred)

Certified coder (preferred)

Tools

Epic

Excel

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.

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

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

Essential Responsibilities

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.

Reporting

Reports To: Manager-Denials Analytics

Supervises: N/A

Other Information

Blood Borne Pathogens: Minimal/ No Potential

Ages of Patients: N/A