Denials Management Analyst I

Where compassion meets innovation and technology and our employees are family.

General Purpose of Job:

Under direct supervision, the Denial Management Analyst will assist with the Billing, Follow-Up, Collection, Root Causing, Recovery, and Reporting of assigned Insurance or Self-Pay claims. Applying a scientific approach, to include research and analysis, the Denials Management Analyst will assist with the discovery of denials or denial trends and offer recommendations for solutions as a denial preventive. Additionally, the Denial Management Analyst will serve as a liaison between entities, promoting opportunities for inclusion and awareness, through communication to stakeholders, as denials or denial trends are discovered.

Essential Duties and Responsibilities:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This job description is not intended to be all-inclusive; employees will perform other reasonably related business duties as assigned by the immediate supervisor and/or hospital administration as required.

The above statements should be included on all job descriptions.

List the job's essential or most important functions and responsibilities. Include all important aspects of the job -- whether performed daily, weekly, monthly, or annually; and any that occur at irregular intervals. Standard functions listed below should be included on all job descriptions.

• Maintains utmost level of confidentiality at all times.
• Adheres to hospital policies and procedures.
• Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines.
• Assist with the Billing, Follow-Up, Collection, Root Causing, Recovery, and Reporting of assigned Insurance or Self-Pay claims.
• Familiarity and adherence to payer timely filing, corrected claim, and appeal deadlines, and apply to assigned claims as necessary.
• Familiarity and adherence to payer reimbursement policies and apply to assigned claims as necessary.
• Familiarity and adherence to payer clinical policies and apply to assigned claims as necessary.
• Familiarity and adherence to Health System contractual agreement(s) and apply to assigned claims as necessary.
• Familiarity and adherence to Texas Administrative Code(s), or Bylaws, and apply to assigned claims as necessary.
• Root cause claim denials and offer recommendation for prevention.
• File appeals as appropriate to resolve payer denials and work with payers to monitor appeals in process.
• Document efforts, conversations as correspondences with clarity and comprehension, within the Electronic Medical Record System.
• Track and trend denials and recovery efforts by utilizing various departmental tools and appropriately reporting on-going problems specific to payers, health system departments, and/or contracts.
• Collaborate with clinical personnel as needed to appeal and resolve assigned claims.
• Ability to communicate effectively with all stakeholders across the health system, furthermore, disseminate denial efforts to key stakeholders as appropriate.
• Maintain a comprehensive payor and managed care intelligence database; to source research and analysis as needed.
• Recommends appeal templates for denial trends, as appropriate.
• Evaluates opportunities and financial terms for the health system.
• Assist with the strategic and financial judgment necessary to achieve profitable growth with payors.
• Supports and participates in the continuous assessment and improvement of the quality of care and services provided.
• Assist departmental leadership in resolving managed care operational issues and provide interpretation of managed care contract language, terms, and conditions.
• Consistently meet the current productivity standards in addressing and resolving denied accounts.
• Consistently meet the current quality standards in taking appropriate actions to identify and track root causes, successfully appeal denied accounts, and trend issues.
• Gather, verify, and evaluate confidential and sensitive organizational information, consistent with assigned claims.
• Provide individual contribution to the overall team effort of achieving departmental goals.
• Demonstrate proficient use of systems and execution of processes in all areas of responsibilities.
• Maintains a sense of professional and self-validation.
• Assure patient privacy and confidentiality as appropriate or required.
• Maintain professional relationships and convey relevant information to other members of the healthcare team, within the facility and any applicable referral agencies.
• Assist with special projects as assigned.
• Other duties as assigned.

EDUCATION AND/OR EXPERIENCE:

Bachelor's degree (B. A.) from four-year college or university; or one to two years related experience and/or training; or equivalent combination of education and experience.

Minimum of one year healthcare experience in a healthcare setting. Outstanding analytical ability and financial skills. Working knowledge of managed care operations and practices preferred. Working knowledge of health system admitting, billing, and utilization review as well as physician office practices, physician credentialing and physician billing practices preferred. Effective communication, organization, and interpersonal skills essential. Work independently. Excellent oral and written communication skills. PC skills necessary with experience in Microsoft Office products, including PowerPoint.