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SalaryResponsible for coordinating denials with Patient Business Service (PBS) center and ensures compliant and complete clinical documentation, assists with denials and related appeals, and identifies opportunities for revenue optimization. Investigates denials and root causes, which includes performing thorough chart reviews, providing education to clinical colleagues and tracking of identified trends. Leverages clinical knowledge and standard procedures to ensure timely attention to denials as requested by PBS and applicable appeal data gathering. Responsible for third party charge audits and trauma reviews. May be require to travel between locations within the Region.
Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, and decisions.
Coordinates denial management processes (i.e., clinical and administrative/technical accounts) for Revenue Integrity department, focusing upon retrospective follow-up, which may include assisting in appeal processing with the objective of appropriately maximizing reimbursement based upon services delivered and ensuring claims are paid/settled in the most timely manner:
- Ensures tracking of denials and all audits, identifying trends, and collaborating with other Revenue Integrity colleagues and PBS on education and reporting to key stakeholders;
- Reviews and understands utilization review and coverage guidelines for multiple payers;
- Identifies solutions to issues affecting reimbursement as it relates to denial prevention (prospective and concurrent);
- Serves as a resource contact, providing clinical information as requested by intra and inter-departmental colleagues and payers;
- Collaborates with Revenue Integrity team on opportunities to improve and implement front-end process to support denial prevention;
- Collaborates with intra-department and PBS teams on accurate documentation and reporting of key performance indicators and participates in development of action plans to ensure goals are met, and
- Supports the development of effective internal controls that promote adherence to applicable local, state, federal laws, and program requirements of accreditation agencies and health plans.
Identifies opportunities for process improvement and participates in the implementation of such as needed. Assists in the design and development of system enhancements while monitoring congruency with process goals and regulatory mandates.
Maintains a strong working relationship with associated ministry Payer Strategy team in order to ensure proper identification, resolution, coordination and alignment of clinical denials with payer environment and expected reimbursement.
Provides detailed understanding or aptitude for resolving denials based on patient status, length of stay, level of care, missing pre-certification, or other clinical reasons and constructing warranted appeals for defined populations.
Interprets data, draws conclusions, and reviews findings with intra and inter-departmental teams.
Coordinates concurrent and retrospective audits of patient medical records and itemized bills, as requested by patient, third party payer, or external auditors.
Keeps abreast of denial trends and regulations concerning healthcare financing and payer relations through journals and professional continued education programs, seminars, and workshops.
Other duties as assigned.
Maintains a working knowledge of applicable Federal, State and local laws/regulations; the Trinity Health Integrity and Compliance Program and Code of Conduct; as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.
Registered Nurse and graduate of an accredited school of nursing plus at least four (4) years of nursing experience, including two (2) years of utilization review/case management, managed care or comparable patient payment processing experience. Must have current registration with the State Board of Nursing Examiners or have a temporary permit to practice nursing in the assigned state. Bachelor's Degree preferred. Must possess a demonstrated knowledge of revenue cycle and denial management functions
Knowledge of and experience in health care including government payers, applicable federal and state regulations, healthcare financing and managed care.
Knowledge of and experience in case management and utilization management.
Outpatient CDI experience preferred.
Knowledge of insurance and governmental programs, regulations and billing processes (e.g., Medicare, Medicaid, Social Security Disability, Champus, Supplemental Security Income Disability, etc.), managed care contracts and coordination of benefits is required. Working knowledge of medical terminology, and medical record coding experience (ICD-9, CPT, HCPCS) are highly desirable.
Customer service background is required. Working knowledge of Electronic Health Records (EHR) is preferred. Ability to interact effectively with multidisciplinary teams, including physicians and other clinical professionals internally and externally.
Possesses detailed understanding or aptitude to learn and understand denials resolution based on patient status, length of stay, level of care, missing pre-certification, or other clinical reasons.
Must possess in-depth familiarity with third party billing requirements and regulations, and writing appeals.
Excellent verbal and written communication and organizational abilities. Accuracy, attentiveness to detail and time management skills are required.
Must be comfortable operating in a collaborative, shared leadership environment.
Must possess a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Trinity Health.
This position operates in a typical office environment. The area is well lit, temperature controlled and free from hazards.
Incumbent communicates frequently, in person and over the phone, with people in all locations on product support issues.
Manual dexterity is needed to operate a keyboard. Hearing is needed for extensive telephone and in person communication.
The environment in which the incumbent will work requires the ability to concentrate, meet deadlines, work on several projects at the same time and adapt to interruptions.
Must be able to set and organize own work priorities and adapt to them as they change frequently. Must be able to work concurrently on a variety of tasks/projects in an environment that may be stressful with individuals having diverse personalities and work styles.
Must possess the ability to comply with Trinity Health policies and procedures.
May be require travel up to 25% between locations within the Region.
The above statements are intended to describe the general nature and level of work being performed by persons assigned to this classification. They are not to be construed as an exhaustive list of duties so assigned.
Our Commitment to Diversity and Inclusion
Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.
