Denials Specialist TC

About the Role

Under general direction and within established Brown University Health policies and procedures, this role maximizes reimbursement from contracted payers through analysis, tracking, and trending of denials using available metric denial reports. The position supports strategic initiatives, process redesign, root cause analysis, metric/report development, and special projects related to denials management. Additionally, the role executes the appeal process by receiving, assessing, documenting, tracking, analyzing, responding to, and resolving appeals with third-party payers.

Employees are expected to role model the organization's values of Compassion, Accountability, Respect, and Excellence, as well as demonstrate core Success Factors: Instill Trust and Value Differences, Patient and Community Focus, and Collaborate.

Responsibilities

• Evaluates denied accounts sent to the Denials Management Department for review and assigns them to appropriate department work queues for resolution.
• Identifies repetitive denial issues to develop preventative solutions.
• Runs reports and follows up with departments to ensure timely resolution of accounts.
• Reviews denial database reports to categorize provider-liable denials, determine root causes, and identify resolutions.
• Performs end-of-month reviews of the denial database to report on trends, new issues, and areas of opportunity.
• Responds to departmental concerns about data on monthly denial reports.
• Develops and maintains strong working relationships with hospital departments and referring physician offices to collaborate on successful appeal/reversal of denials.
• Maintains current knowledge of state and federal regulations, accreditation and compliance requirements, Brown University Health policies, and payer-specific policies, including LCDs, NCDs, and payer contracts.
• Researches payer issues causing payment delays, denials, underpayments, and processing deficiencies, and recommends changes as appropriate.
• Reviews monthly payer updates and prepares reports for the monthly Appeal/Denial meeting.
• Tracks the status of appeals by maintaining organized records to ensure established timelines are met.
• Maintains strong working relationships with payers to ensure claim appeals are processed appropriately.
• Processes necessary LifeChart online adjustments or changes related to appeals as needed.
• Evaluates workflows and identifies opportunities to improve processes for full and complete payment for all hospital services.
• Creates, generates, and maintains ad hoc reports as requested by the Manager.
• Participates in staff meetings, councils, quality improvement teams, and other required committees.
• Develops and maintains working relationships with Brown University Health affiliate departments to ensure full data exchange.
• Performs other duties as necessary.

Work Location & Expectations

After orientation at the Corporate facilities, work may be performed in one of the following options, approved by management and adhering to a signed telecommuting work agreement and Patient Financial Services Remote Access Policy:

• Full-time schedule worked in the office.
• Full-time schedule worked in a dedicated space at home.
• Part-time schedule split between the office and a dedicated home space.

Schedules must be approved in advance by management and allow for flexibility without interfering with job functions. Staff are required to participate in scheduled meetings and be available to management throughout their scheduled hours. Staff must be signed into Microsoft Teams during their entire shift and communicate with their Supervisor as directed.

Requirements

• Associate’s degree in accounting, business office practices, computer science, or a related area, or equivalent experience.
• Three to five years of experience in hospital patient accounting, demonstrating thorough knowledge of claims administration in a complex healthcare organization.
• Familiarity with ICD-9/10, CPT-4 coding, UB04, and HCFA 1500 claims administration.
• Ability to perform financial analysis.
• Comprehensive knowledge of patient accounting activities in an automated, networked, multi-hospital environment.
• Detailed knowledge of regulatory requirements.

Schedule

Work Type: Monday through Friday, 8 AM - 12 PM (4 hours per day).