Specialist-Quality Assurance Denial Escalation

Summary

The Denial Mitigation Specialist – Denial Escalation Quality Assurance evaluates the adequacy and effectiveness of internal and operational controls designed to ensure that processes and practices lead to appropriate adjudication of claims. This role requires thorough understanding of regulatory requirements, managed care contract terms, facility-specific internal guidelines, revenue integrity, billing, cash applications, payment variances and adjustment processing including federal and state regulations and guidelines. The Quality Assurance Specialist will be responsible for analyzing and interpreting trends associated with inventory and weekly departmental reporting.

The position will require thorough analysis and interpretation of payer contracts as well as state and federal regulatory guidelines in order to maximize revenue realization. Efforts previously described will result in increased net revenues by reducing bad debt from potential write-offs due to lack of collections and overturns on payer denials through the appeals process. The role will collaborate with upper management to analyze and report trends associated with the write off and appeals processes.

Responsibilities

Conduct audits to determine organizational integrity of upstream, midstream and downstream revenue cycle activities that impact the adjustment processing of claims.

Conducts risk assessments to define audit priorities by evaluating previous audit findings, management priorities and current volumes of adjustments.

Complete special AR projects to help liquidate key segments of Baptist aging AR

Prepare and submit reconsiderations and appeals to timely filing denials and follow up with payors for outcomes.

Review all timely filing adjustments to determine whether Baptist has exhausted all attempts to appeal and overturn timely filing denials.

Appeal denials for payer external review and state escalations

Communicate audit results to hospital service departments and departmental leadership, and make recommendations for management corrective action.

Serve as institutional subject matter experts and authoritative resources on interpretation of contract language to ensure appropriate reimbursement by insurance companies.

Performs scheduled and unscheduled independent audits of revenue integrity and business office activities.

Conducts routine retrospective and prospective account audits as directed by revenue cycle system director.

Assess internal and external communication of changes to better communicate across functional departments.

Adheres to the defined audit timeline and audit protocol standards; assists with development of the audit schedule; identifies services to be audited.

Annually identifies specific needs for self-development and implements a plan to achieve professional growth.

Applies consistent and standardized compliance audit methodology for sample selection, scoring and benchmarking, development and reporting of findings and repayment calculations.

Prepares written reports of audit findings and recommendations and presents to specific business offices; evaluates the adequacy of management corrective action to improve deficiencies; maintains audit records.

Participates in the development of the department long-term and short-term goals, objectives plans, policies and procedures.

Contributes to a positive work climate and the overall team effort of the department.

Requirements, Preferences and Experience

Experience

DescriptionMinimum RequiredPreferred/Desired

Minimum of 2-4 years experience in dynamic healthcare (clinic, physician, or acute hospital setting) or payer environment performing activities such as patient collections, payment applications, denials, registration and/or scheduling required. Appeal writing and payer experience preferred.

Extensive understanding of Revenue Cycle functions, flow, and operation.

Education

DescriptionMinimum RequiredPreferred/Desired

High School Diploma or equivalent required.

Preferred: Associates Degree related to Health Care or Information Technology.

Training

DescriptionMinimum RequiredPreferred/Desired

2 years of experience in the healthcare industry with a working knowledge of hospital or physician revenue cycle functions.

Detailed knowledge of revenue cycle work strams and revenue flow; Revenue cycle process management; Moderate systems expertise; Moderate experience with facility and professional billing requirements.

Special Skills

DescriptionMinimum RequiredPreferred/Desired

In depth knowledge of industry payer and governmental specific rules, regulations, policies, laws, and guidelines, that impact financial impact revenue reimbursement as it relates to applicable departments. .

Ability to comprehend payer responses in all forms of communication..

Professional Writing Skills.

Excellent Customer Service and communication skills (verbal and written).

Time management and flexibility to meet work schedule demands.

Good judgement and problem solving skills (escalation process.)

Ability to work with a high degree of confidentiality.

Ability to manage multiple tasks simultaneously and adjust to issues as needed in a dynamic work environment.

Proven ability and/or expressed willingness to work as part of a team.

Privacy, Safety and Security- the individual observes privacy, safety and security procedures and uses equipment and materials properly.

Competent utilizing Microsoft office, Excel, PowerPoint

About Baptist Memorial Health Care

At Baptist, we owe our success to our colleagues, who have both technical expertise and a compassionate attitude. Every day they carry out Christs three-fold ministry-healing, preaching and teaching. And, we reward their efforts with compensation and benefits packages that are highly competitive in the Mid-South health care community. For two consecutive years, Baptist has won a Best in Benefits award for offering the best benefit plans compared with their peer groups. Winners are chosen based on plan designs, premiums and the results of a Benefits Benchmarking Survey.

At Baptist, We Offer:

Competitive salaries

Paid vacation/time off

Continuing education opportunities

Generous retirement plan

Health insurance, including dental and vision

Sick leave

Service awards

Free parking

Short-term disability

Life insurance

Health care and dependent care spending accounts

Education assistance/continuing education

Employee referral program

Job Summary:

Position: 19873 – Supervisor-Quality Assurance Denial Escalation

Facility: BMHCC Corporate Office

Department: HS Denial Mitigation Corporate

Category: Finance and Accounting

Type: Non Clinical

Work Type: Full Time

Work Schedule: Days

Location: US:TN:Memphis

Located in the Memphis metro area REQNUMBER: 24098