Denial Management Coordinator

Position Summary

The Denial Management Coordinator oversees the coordination and tracking of Rochester Regional Health responses to CMS Recovery Audit Contractor (RAC), MAC, and CERT pre and post-payment reviews as well as medical necessity and/or DRG denials for non-governmental commercial payers for both inpatient and outpatient encounters. Demonstrates knowledge of healthcare compliance, revenue cycle, and audit recovery activities.

Key Responsibilities

• Cover all denial inquiries to ensure all submissions are within mandated timeframes.
• Aid in written responses and collection of all required information through the adjudication process to ensure completeness, comprehensiveness, and persuasiveness.
• Prioritize review of claims by evaluating due dates and impact on revenue and volume.
• Receive, log, and track all denial activity and correspondence for government and commercial payers for both inpatient and outpatient.
• Maintain an accurate database of all denial activity to closure to help manage and track denial hand-offs between departments.
• Develop and maintain clear communication channels with internal insurance reviewers and recovery audit contractors.
• Utilize aggregate denial activity data to provide HIM Leadership with information supporting the health system in identifying areas needing policy, procedure, or process improvements related to documentation, coding errors, and/or utilization management issues.
• Work closely with Physician Advisor team to escalate issues and educate providers on emerging issues.
• Partner with HIM Leadership and key health system personnel to minimize risk of past and future payment errors identified by federal and state contractors as well as private insurers.
• Identify common and overlapping issues and alert health system leadership of targeted service lines.
• Develop and prepare various reports for RRH Senior Leadership, key medical staff, and clinical department leadership.
• Work with the Denials Specialist and Physician Advisor leadership to develop and refine policies and procedures ensuring standard processes are in place across the system.
• Develop and document procedures and training materials for data collection within the denial tracking software.
• Train new staff on processes and software functionality.
• Coordinate ad hoc meetings, as needed, on an immediate basis; if denial activity requires swift review and determination of health system response.
• Provide RRH Leadership with updates on process changes or present and future denial regulations and/or modifications.
• Maintain access to the database tracking mechanism to include adding new users and deactivating users as applicable.

Desired Attributes

• Experience with claim denials, audit management, and appeal processing.
• Current certification as an RHIA, RHIT, RN, CCS, or CCS-P.
• Knowledge of medical necessity, coding, and documentation guidelines for Medicare, Medicaid, and other third-party payers.
• Experience with Epic EHR.
• Experience in preparing and presenting educational material to staff and providers.

Minimum Qualifications

• AAS or two or more years of relevant work experience within the healthcare revenue cycle, e.g. Patient Access, HIM, PFS, or other role related to denial management.
• Licensure/Certification: RHIT or RHIA; CCS preferred.
• Earned coding credential of Certified Coding Specialist (CCS) preferred.

Physical Requirements

• Sedentary Work - Exerting up to 10 pounds of force occasionally.

Pay Range

• $19.75 - $24.50

City

• Rochester

Postal Code

• 14617