DENIALS MANAGEMENT COORDINATOR

Responsible for developing, implementing and managing a centralized program to promote greater efficiency with completing, tracking, and reporting coding and retro audit reviews to determine the appropriate appeal of patient accounts.

Combines clinical, business, and regulatory knowledge and skill to reduce significant financial risk and exposure caused by denial and audit of claims billed for rendered services.

Through continuous assessments, problem identification, and education, this individual facilitates the quality of health care delivery in areas of inpatient coding, DRG, outpatient, professional coding, medical necessity, government, and commercial payer requirements.

Furthermore, the individual routinely analyzes data related to payer audit and denial trends specific to coding-denial and takeback concerns.

This position works closely with HIM and CDI as well as key stakeholders across Revenue Cycle.

• Reviews and analyzes current audit information to identify opportunities for improvement internally and payers.
• Maintains reporting specific to audit statuses, identifying internal and payer patterns to better manage payer issues proactively.
• Update and maintain audit tracking spreadsheets outside of RAC software.
• Develop and maintain procedural documentation.
• Identify and resolve system and payer issues that result in payment delays, incorrect payments.
• Service as a PFS, PAS, HIM, Compliance, Contract Management, Clinical Liaison to third party payers, and other parties in a problem-solving or information capacity.
• Monitor deadlines and ensure all parties meet timely filing for appeal deadlines.
• Assist with auditing involving any third-party commercial payer.
• Participate in payer meetings to discuss appeal progress and identify trends with payer processing appeals to resolve cases.
• Establish and enforce internal audit policies including pre-payments audits.
• Collect and analyze data from audits and concurrent reviews to identify recurring problems.
• Acts as a coordinator and mentor to RID Denial Staff.

Minimum of an Associate’s Degree in Business, Paralegal Studies, Coding, Healthcare, or related field.

T wo (2) years of relevant experience in Compliance, Coding, HIM, Insurance denials, or Legal experience may be considered in lieu of an Associate’s degree

Minimum three (3) years’ experience within the healthcare field performing any variety of organizational, administrative, or process improvement functions.

Preferred experience:

Experience in compliance, coding, insurance denials, and/or a legal setting.

or background in denials management.

working with 3 rd party payers.

• Excellent oral and written communication skills.
• Establish and maintain professional and cooperative relationships.
• Efficient and effective analytical skills.
• Ability to research regulatory requirements.
• Effective human relations abilities.
• Proficiency with Microsoft applications and other applicable software and database management applications.
• Effective problem-solving abilities.
• Strong ability to effectively collaborate alliances and promote teamwork.