Denials Management Specialist

FLSA STATUS

Exempt

• Graduate of education program approved by the credentialing body for the required credential(s) indicated below in the Certifications, Licenses and Registrations section.
• Bachelor of Science preferred

• Seven years clinical nursing/patient care experience with five years in utilization review with clinical decision tools such as Interqual, Millimann, etc, case management or equivalent revenue cycle clinical role, including past experience in initiating and facilitating physician peer to peer review, medical/clinical denials and appeals
• Must have experience with prior authorization process for all providers, ordering and rendering.

Required

• LVN - Licensed Vocational Nurse - State Licensure - Texas Department of Licensing and  license in the state Texas

Preferred

• CPHM - Certified Professional in Healthcare Management (McKesson)
  and
• CCM - Certified Case Manager (CCMC)
  and
• ACM - Accredited Case Manager (NBCM,ACMA) or equivalent

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
• Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
• Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
• Extensive knowledge of clinical symptomology and related treatment and hospital utilization management
• Knowledge of current reimbursement models: commercial, managed care, government and the technical writing ability to develop and formulate appeal letters and reports
• Ability to communicate both verbally and in writing to a varied of audience including all levels of personnel, physicians, clinical staff, management, and revenue cycle staff
• Motivated and can act independently with minimal supervision
• Excellent listening skills
• Knowledge of medical and insurance terminology and medical record coding (ICD
  10, CPT/HPCPCS, etc.)
• Advanced proficiency in word processing (MS Word) and proficient in basic spreadsheet applications (Excel)
• Knowledge of electronic health record system
• Demonstrated ability to interact effectively with interprofessional teams, including physicians, and other professionals both internal and external to Houston Methodist
• Maintains knowledge of Federal, State, and local billing regulations and partners with managed care contracting
• Maintains knowledge of ADT, registration and pre-admit/admit workflow processes.
• Maintains knowledge of contracts, billing/follow up procedures
• Demonstrates strong knowledge of commercial insurance and governmental programs, state and federal regulations and billing processes, managed care contracts and coordination of benefits related to coverage, clinical appeals and denials to include knowledge of CPT and ICD codes and familiarity with Local Coverage Determination (LCD)/ National Coverage Determination (NCD)
• Competence in writing clinical appeals for medical necessity compliance or level of care for government and nongovernmental payors
• Ability to develop an appeal strategy and facilitate clinical appeals to ensure recovery

• Trains staff in denials and appeals process, denial management, and medical coverage guidelines. Serves as an educational liaison to clinical, revenue cycle, central business office and facility operational staff, as needed, on payor denials, denial reason and trending, interpretation of payor manuals, medical policies and local/national coverage determinations or other regulatory requirements related to denials and appeals. Contributes to improving department employee satisfaction/engagement.
• Assists in mitigating avoidable denials by communicating directly with physicians, case management staff, clinical service areas, department staff, CBO partners, and vendors to convey payor requirements and reasons for…