Denials Management Analyst II

Job Title: Denials Management Analyst II

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.

• Identify process errors in the organizational system or teams and assist in creating ways to limit them from occurring.
• Work alongside Denials Manager with acting as liaisons between department heads and payers.
• Exceptional decision-making skills when it comes to determining next steps in the appeals process.
• Be strategic in the data analysis process.
• Assist in meetings between Department leaders.
• 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.

Supervisory Responsibilities:

Effectively administers performance management system including:

• developmental feedback
• goal setting
• assesses competency
• progressive discipline
• Strong knowledge of and effective in administering hospital policies and procedures.
• Responsible for sound management of human resources.
• Makes and implements decisions compatible with organizational goals.
• Maintains composure, effectiveness, and flexibility under pressure.

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. Experience with denials preferred.
• Understanding of payers, and coding experience preferred. 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 are essential.
• Work independently.
• Excellent oral and written communication skills.
• PC skills necessary with experience in Microsoft Office products, including PowerPoint.