The Denial & Appeals Coordinator is responsible for denial and appeals claim processing for medical providers, facilities and laboratories, ensuring compliance and contractual obligations and State and Federal laws and regulations and generating appeals for denied or underpaid claims.
This position does not have any direct reports
NATURE AND SCOPE
Interacts with patients and their families; staff members; physicians and other healthcare providers; and Hospital and University officials.
- Validate denial/code reasons following explanation of benefit (EOB); review and ensure coding is accurate and reflects procedures billed.
- Analyze all coding adjustments made on EOB to ascertain accuracy and valid support
- Review Summary Plan descriptions and related insurance documents to ascertain benefits
- Determine and execute best approach for denial resolution and processing appeal
- Ensure timeliness of all appeals according to Federal, State and plan guidelines
- Generate appeals based on the dispute reason(s)
- Document all actions taken during the appeal process and any follow-up required
- Request and obtain medical records, notes and/or copy of claim as appropriate
- Resolve appeal claims with third party payers
- Assist with Appeals Team efforts to coordinate problem solving in an efficient and timely manner
- Assumes other duties and responsibilities that are related and appropriate to the position and area. The above responsibilities are a general description of the level and nature of the work assigned to this classification and are not to be considered at all-inclusive.
- Promotes adherence to the Health Sciences Compliance Program, the Howard University Code of Ethics and the Health Sciences Standards of Conduct.
- Attends annual and periodic mandatory Compliance Program training including the Health Insurance Portability and Accountability Act (HIPAA) training.
- Participates in activities that promote adherence to federal healthcare program requirements.
- Actively participates in Health Sciences Compliance Program activities.
- Adheres to the requirements of the HIPAA Privacy Policies and Procedures.
- Maintains confidentiality of patients, families, and staff.
- Must demonstrate collaboration; accountability; respect; excellence; and service.
- Works with team members and peers in and outside of their immediate work group to create an exceptional experience for patients, students and other visitors.
- Accepts responsibility for his/her actions to provide health care and/or ancillary functions in a highly efficient and compassionate manner. The employee must function as a Steward of Howard values that foster a commitment to improving the patient and student experience, organizational efficiency and the environment.
- Embraces diversity and cares holistically for those the Hospital serves.
- Manages the patient’s right to privacy with meticulous care and keeps patient and proprietary information about the institution confidential.
- Anticipates the patients’ and students’ needs, presents as a model representative of the institution and maintains high standards of care while striving to improve performance and create exceptional experiences for our customers.
- Behaves in a friendly, resourceful and professional manner towards all they encounter; treats patients, students and visitors in the same way that they would want their family members or themselves to be treated.
- Proficient in Microsoft Office programs (Excel, Word and Outlook)
- Comprehensive knowledge of healthcare customer service, regulatory requirements and Provider Dispute and/or Member Appeal process.
- Working knowledge and a thorough understanding of denial resolution strategies and payer reimbursement specifics
- Knowledge of CPT/HCPC, ICD/10 coding, procedures and guidelines
- Analytical skills
- Excellent written and communication skills
- Ability to establish and maintain effective and harmonious work relationships with staff, physicians, Hospital and University officials, and the general public.
- High School diploma and/or equivalent education
- 3+ years of medical appeals/medical coding experience
- Must be able to stand, walk, sit, lift (lbs), bend, write, type, file, speak, hear, see, calculate, compare, edit, evaluate, interpret and organize for extended periods of time.