Address
Form of work
SalaryHybrid Schedule: Full-time, Monday-Friday (4 days remote, 1 day on-site)
Location: 41 University Drive Newtown, PA 18940
This person will be responsible 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.
Responsibilities include, but not limited to:
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.
Minimum Qualifications:
Active PA RN License required
Bachelor's Degree preferred
At least 2-4 years' experience in utilization review or case management as well as managed care or comparable patient payment processing experience required.
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.
Knowledge of insurance and governmental programs, regulations and billing processes. Working knowledge of medical terminology, and medical record coding experience (ICD-9, CPT, HCPCS) are highly desirable.
We offer a competitive salary and comprehensive benefits including:
Medical, Dental, & Vision Coverage (Effective First day of Hire)
Retirement Savings Program
Paid Time Off
Tuition Reimbursement
Free Parking
And more!
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.
