Job Summary - Researches and Resolves High Dollar Technical and Top Dollar Clinical Appeals through concise understanding of Payer Contract Language and Clinical or Technical justification. Position requires individuals with high mathematical acumen, ability to access and assimilate data, articulate a strong case, confidence, and strong persuasion skill set. Results oriented individual will be required to work through various options available to liquidate the most difficult top dollar appeals. Candidate will demonstrate ability to grow strategic payer relationships and obtain understanding of payer system to navigate through the appeals process. Critical thinking skills are necessary, as well as ability to see trends that require escalation to the Payment Compliance Director. Responsible for bundling similar cases not resolved through the standard Payment Compliance process and escalate to Dispute Resolution Team for legal action.
Duties (included but not limited to):
Review technical and clinical denial arguments for reconsideration on top dollar accounts, including both written and telephonically through resolution process.
Identify coding or clinical documentation issues and work to correct the errors in a timely manner.
Identify contract protection that can be leveraged to overturn denials.
Overcome objections that prevent payment of the claim and gain commitment for payment through concise and effective appeal argument.
Identify problem accounts/processes/trends and escalate as appropriate.
Utilize effective documentation standards that support a strong historical record of actions taken on the account.
Identifies and communicates contract interpretation issues and language discrepancies to leadership as appropriate.
Identifies Payer company trends and communicates trends to supervisor for further action/escalation.
Serves as a subject matter expert in payer appeals resolution process.
Practices and adheres to the "Code of Conduct" philosophy and "Mission and Value Statement"
Other duties as assigned
Knowledge, Skills & Abilites
Communication - communicates clearly and concisely, verbally and in writing.
Persistence – comfortable pursuing, rebutting and escalating issues as appropriate.
Goal-oriented – holds him/herself accountable to achieving shared and personal goals.
Customer orientation - establishes and maintains long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations.
Interpersonal skills - able to work effectively with other employees, patients and external parties.
PC skills - demonstrates high proficiency in Microsoft Office applications and others as required.
Policies & Procedures - demonstrates knowledge and understanding of organizational policies, procedures and systems.
Mathematical skills - able to perform advanced mathematical calculations and balance and reconcile figures
Writing skills –advanced writing skills with ability to present a compelling argument, punctuate properly, spell correctly and transcribe accurately.
Join our HealthONE family -- the largest healthcare system in the Denver metro area. Eight world-class hospitals. 40+ outpatient facilities. Countless opportunities.
HealthONE is an equal opportunity employer.