Denials Management Representative

Summary

Position Summary
The Denials Management Representative performs a wide range of duties involving the resolution of claims denied or delayed processing by insurance carriers.  Identifies, monitors and resolves issues resulting in the denial of claims. Takes corrective action to facilitate the re-billing and/or appeal of claims and the subsequent reimbursement of originally denied claims.  Identifies, analyzes, and researches frequent root causes of denials and assists management in developing corrective action plans to prevent future denials.

Essential Duties

1. Generates appeals based on the denial reason and contract terms of the payors. This includes online provider disputes and reconsiderations. Follows specific payor guidelines for appeals submissions, paying close attention to the timelines for appeals. Escalate exhausted appeal efforts for resolution. 
2. Works closely with managed care organizations, third party payors, government payors and internal staff to ensure compliance to contract requirements and/or state/federal regulations in order to expedite reimbursement of claims and protect National Jewish Health (NJH) from unnecessary financial loss. 
3. Thorough and consistent follow up on unpaid /denied claims by utilizing monthly aging reports, worklists and queries, claim status with the payor, utilizing all systems, websites and tools available to effectively research claims and resubmit or appeal as necessary. 
4. Communicates regularly with PFS Supervisor and/or Manager regarding high-risk accounts, including but not limited to accounts that have aged beyond 90 days old, inpatient accounts, and high dollar accounts. 
5. Maintains a thorough knowledge of NJH payor contracts, utilizing the contract matrix and communicating with Contracting and Reimbursement when necessary. Has a thorough understanding of state and federal regulations, including but not limited to various reimbursement methodologies depending on the services billed and claims editing content. 
6. Contacts insurance companies using proper negotiation and/or persuasion techniques to elicit claim resolution, including but not limited to: problem solving, complex mathematical proficiency, resolving eligibility, claims billing, claim follow up and/or other related obstacles causing denials. 
7. Makes necessary arrangements for medical necessity letters, medical records requests, and any additional information as requested by insurance companies to ensure timely resolution of outstanding denied/unpaid claims. 
8. Prioritizes claims based on aging and outstanding dollar amounts, or as directed by management. Work daily with automated worklist, ATB and/or assigned special projects in the patient accounting system to perform account audits of insurance payments. 
9. Maintains a thorough understanding of CPT, HCPCS & ICD-10 codes, HCFA and UB04 claim forms, DRG, insurance benefits including authorizations/referrals. 
10. Identifies self-pay accounts and potential bad debt accounts for referral to outside agencies or attorneys for further collection efforts.

Other Duties

1. Responds timely (within 24 hours or next business day) to account inquiry calls from patients or insurance companies. Researches claims or account questions with responsible department and provides customers with requested financial information or refers them to other resources at National Jewish Health.  
2. Provides PFS Supervisor and reports weekly productivity statistics and reports workload fluctuations (backlog or shortages) in a timely manner. Maintains individual goals established by PFS management. 
3. Actively participates in team and departmental meetings by sharing ideas for improved work processes in PFS and performs as a back-up to staff absences and vacancies, as necessary.

Competencies

1. Decision Making: Identifying and understanding issues, problems, and opportunities; comparing data from different sources to draw conclusions; using effective approaches for choosing a course of action or developing appropriate solutions; taking action that is consistent with available facts, constraints, and probable consequences.
2. Problem Solving: Uses issue identification, data relation and comparison, pattern recognition and information gathering to create analyses and make recommendations.
3. Perseverance/Resourcefulness: Accesses and utilizes available resources inside and outside the company.
4. Accountability: Accepts full responsibility for self and contribution as a team member; displays honesty and truthfulness; confronts problems quickly; displays a strong commitment to organizational success and inspires others to commit to goals; demonstrates a commitment to Patient Financial Services Departments and National Jewish Health.
5. Attention to Detail: Accomplishing tasks by considering all areas involved, no matter how small; showing concern for all aspects of the job; accurately checking processes and tasks; being watchful over a period of time. Setting high standards of performance for self and others; assuming responsibility and accountability for successfully completing assignments or tasks; self-imposing standards of excellence rather than having standards imposed.
6. Adaptability: Maintaining effectiveness when experiencing major changes in work responsibilities or environment; adjusting effectively to work within new work structures, processes, requirements, or cultures.
7. Drive for Results: Setting high goals for personal and group accomplishment; using measurement methods to monitor progress toward goals; tenaciously working to meet or exceed goals while deriving satisfaction from that achievement and continuous improvement.
8. Managing Work and Time: Effectively managing one’s time and resources to ensure that work is completed efficiently. Effectively manages project(s) by appropriately focusing attention on the critical few priorities; effectively creates and executes against project timelines based on priorities, resource availability, and other project requirements (i.e., budget); effectively evaluates planned approaches, determines feasibility, and makes adjustments when needed.

Supervisory or Managerial Responsibility
None

Travel
None

Core Values

1. Be available to work as scheduled and report to work on time.
2. Be willing to accept supervision and work well with others.
3. Be well groomed, appropriately for your role and wear ID Badge visibly.
4. Be in compliance with all departmental and institutional policies, the Employee Handbook, Code of Conduct and completes NetLearning by due date annually.
5. Fosters an inclusive workplace where diversity and individual differences are valued and leveraged to achieve the vision and mission of the institution.
6. Adheres to safe working practices and at all times follows all institutional and departmental safety policies and procedures. 
7. Wears appropriate PPE as outlined by the infection control policies and procedures.
8. Demonstrates compliance with all state, federal and all other regulatory agency requirements.

Minimum Qualifications

1. Education: High school graduate or equivalent required.  Some college level course work, preferred. 
2. Work Experience: A minimum of 5 years of recent and related healthcare experience is required. A minimum of five 5 years in hospital billing/collection/follow up, accounting and customer service environment is required. 1 to 2 years of NJH specific account representative experience preferred.
3. Special Training, Certification or Licensure: None

Salary Range: $20.00 - $24.00

Benefits
At National Jewish Health, we recognize that our outstanding faculty and staff are the essence of our organization. For every aspect of health care, our employees are our greatest asset.
With that in mind, we have designed a valuable, comprehensive benefits package to meet the needs of our employees and their families.

• Medical Plans, Dental Plans and Vision Insurance
• Retirement Plan
• FSA and HSA
• Short and Long Term Disability
• Life Insurance and AD&D
• Voluntary Benefits, like Accident Insurance, Critical Care and Hospital Indemnity
• Sick and Vacation Paid Time Off
• Wellness Program
• Legal Plan