[Hiring] Denial Resolution Specialist II @UMass Memorial Health

Role Description

Responsible for reviewing, analyzing and initiating appropriate action for complex denial resolution by communicating with payers, hospital departments and patients.

• Triages denial root cause and executes appropriate next steps.
• Identifies trends and participates in interdepartmental resolution strategies to reduce and eliminate future denials. Researches complex denials as assigned.
• Trains staff on payer websites, providing basic guidance and instruction on website navigation.
• Uses assigned work queues and prioritization standards and guidelines to perform denial resolution follow up.
• Resolves accounts denials with high dollar balances (>$100,000) recognizing the potential complexity and the need for rapid resolution.
• Uses reference material to troubleshoot payer issues and increase understanding of denial resolution techniques.
• Analyzes and researches the denial reasons for each assigned denial code. Recognizes and differentiates between claim denials and payment variances.
• Participates in payer and internal audits. Supports requests for information, claim correction and/or resubmission.
• Corrects and updates claim information in the Medicare FISS system requiring in depth knowledge of Medicare billing and compliance regulations.
• Correct and resubmit claims in Mass Health MMIS and other payer websites.
• Completes appropriate actions needed for an effective appeal including conducting authorization research, rebilling, and balance write off or transfer to next responsible party.
• Corresponds with third party payers, hospital departments, and patients to obtain information required for denial resolution following payer timelines.
• Follows payers established procedures and timelines to submit appeals utilizing payers preferred method.
• Documents all actions taken during the denial resolution process clearly.
• Adjusts account balances using correct transaction while code adhering to guidelines.
• Follows established protocols to ensure all documents are retained appropriately.
• Meets established quality and productivity standards.
• Facilitates and promotes the sharing of knowledge and content throughout departments.
• Follows all established Hospital Billing Revenue Cycle Management departmental and compliance policies and procedures.
• Adheres to change control processes.
• Participates in cross training to optimize resources.
• Demonstrates excellent attendance and actively participates in a variety of meetings and training sessions as required.
• Maintains and fosters an organized, clean, and safe work environment.
• Actively contributes to the development and application of process improvements.
• Maintains a collaborative, team relationship with peers and colleagues.
• Demonstrates respect for the diversity of patient and employee populations.
• Practices cost containment and fiscal responsibility through the efficient use of supplies, equipment, time, etc.
• Performs a variety of related duties as assigned by management.

Qualifications

• A minimum of a High School diploma.
• Four or more years of experience in health care billing functions.
• Previous health care billing experience.
• Proven track record of successful performance and goal achievement.
• Experience in denial resolution process.
• Advanced knowledge of claim form content and claim submission requirements.
• Proactively proposes resolutions to issues.
• Ability to communicate verbally and clearly document all actions taken during resolution process.
• Demonstrates ability to research denial issues.
• Ability to navigate in MassHealth claims processing application and/or the Medicare claims processing application.
• Experience with high dollar- high complexity claim submissions.
• Ability to work collaboratively and effectively with people.
• Exceptional communication and interpersonal skills.

Requirements

• Unless certification, licensure or registration is required, an equivalent combination of education and experience which provides proficiency in the areas of responsibility listed in this description may be substituted for the above requirements.

Physical Demands and Environmental Conditions

Work is considered sedentary. Position requires work indoors in a normal office environment.