Denials Analyst / Appeals - Mon - Fri 8:00am - 5:00pm - Northeast Georgia Health System, Inc

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Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

About the Role:

Job Summary

Ensures correct identification and root cause of payer denials.  Initiate comprehensive appeal process to include contacting insurance companies to justify and resolve denials, as well as arranging for correct payment recovery. Works closely with the department manager on trending and reducing denials. Communicates appropriately to "Source Department" of denials to educate and troubleshoot.
 

• Licensure or other certifications:

• Educational Requirements: High School Diploma or GED

• Minimum Experience: Three (3) or more years of reimbursement experience to include insurance follow-up and collections experience.

• Other:

• Preferred Licensure or other certifications:

• Preferred Educational Requirements: Associates Degree.

• Preferred Experience:

• Other:

• Working knowledge of managed care contracts, HCPCS, DRG and other billing and reimbursement methodologies

• Understanding of ANSI claim adjustment reason codes and ANSI remittance advice remark codes

• Ability to display a positive attitude

• Excellent analytical, communication and negotiation skills  

• Expert knowledge of UBO4 and EOB experience, knowledge with calculating expected reimbursement for hospital claims

• Extensive understanding of Managed Care reimbursement methodology with the ability to analyze Managed Care Contracts

• Expert knowledge of the patient accounting system, knowledge in Managed Care and billing practices revenue codes and CDM Codes

• Ability to work a denial through the life cycle of the appeals process timely and efficiently  

• Ability to work independently and as part of a cohesive team 

• Ability to complete multiple activities utilizing multiple applications efficiently and professionally  

• Evaluates MedAssets Contract Manager expected reimbursement calculation to final payer payment to avert risk of net revenue loss to Northeast Georgia Medical Center (NGMC). Acts as subject matter expert for multiple, complex payer contracts to fully understand all scenarios of reimbursement due to NGMC. Manages a working inventory of identified payment discrepancies and denials for payment resolution. Analyzes payer denials and provide appropriate feedback to department manager when trends are identified. Identifies and corrects internal issues, such as incorrect revenue codes billed, to maximize potential net revenue reimbursement.

  Serves as payer liaison between the variance collections department and other departments, such as managed care and patient financial services.

• Pursues additional net revenue due to NGMC as a result of denied claims. Determines appropriate accounts to appeal for additional monies lost due to denials/underpayments. Prepares and submits correspondence, such as letters, emails, fax, and online inquiries to fully and comprehensibly explain reasons for appeal. Documents results of appeal process to accurately reflect reasons NGMC did not recover revenue, keeping in mind that documentation may be utilized in future legal actions.

• Reports contract compliance to appropriate parties, both internally and externally, as required. Follows up and escalates issues to upper management, such as payer non-compliance, to ensure managed care is constantly aware of payer contract compliance. Analyzes payment recoveries through root-cause analysis and report findings to department manager on a weekly basis. Attends payer meetings to present problem accounts requiring second and third level appeals to upper levels of payer management for payment resolution.

• Collaborates on special projects to ensure appropriate contract compliance and assist with revenue cycle operations as needed. Manages special projects, as the needs present, to resolve compound reimbursement issues that may affect hundreds of accounts. Works in partnership with areas such as patient financial services, managed care, and revenue management to avoid revenue leakage to NGMC.

  Works closely with the PFS government analyst to ensure CMS guidelines are followed and if any issues that may result in a compliance issue are reported to the Compliance Committee. Gains knowledge of payer regulations and other payer updates, such as CCI edits, by working with managed care to facilitate and comprehend the correct reimbursement that is due to NGMC. Supports management to capture denial root cause analysis and prepares and supports data presentation to respective physician specialties, senior leadership, revenue cycle and Department Directors as appropriate. Accesses and understands Governmental data bases ensuring payer rationale for specific denial reasons, as well as, shares and elicits support from the medical staff to formulate a response to specific denials where indicated.  Participates as a vital member of the denial management team relating to denial reporting and trending.  
   

• Weight Lifted: Up to 20 lbs, Occasionally 0-30% of time

• Weight Carried: Up to 20 lbs, Occasionally 0-30% of time

• Vision: Heavy, Frequently 31-65% of time

• Kneeling/Stooping/Bending: Frequently 31-65%

• Standing/Walking: Frequently 31-65%

• Pushing/Pulling: Frequently 31-65%

• Intensity of Work: Frequently 31-65%

• Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding

Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals. 

NGHS: Opportunities start here.

Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.