OP Clinical Denial Specialist - Per Diem

Job Description

Overview

The following information provides an overview of the skills, qualities, and qualifications needed for this role.

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values.

These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.

The OP Clinical Denial Specialist supports the organization by reducing financial liability and recovering lost revenue for coding and medical necessity denials.

This individual is responsible for managing medical denials by conducting a comprehensive review of clinical documentation, writing compelling arguments based on the clinical documentation and the medical policies of the payor, submitting appeals in a timely manner, and identifying / resolving denial trends to mitigate potential loss.

The OP Clinical Denial Specialist will also handle audit-related / compliance responsibilities and other administrative duties as required.

This individual works closely with colleagues within the organization and with managed care payers to resolve issues and expedite reimbursement on overturned appeals.

EEO / AA / Disability / Veteran

Responsibilities

• Researches payer denials related to medical necessity, coding, etc., resulting in denials and delays in payment.
• Evaluates Outpatient Clinical denials against medical record documentation, the coding of the encounter, payer policies and contracts, and coverage determinations to determine the viability of an appeal.
• Compiles the supporting documentation by working in partnership with internal departments and uses technology, drafts detailed, customized appeal letters to payers in accordance with Medicare, Medicaid, Commercial, and YNHHS policies and procedures.
• Ensures and tracks receipt of appeals and timely follow-up with all submissions until determination is made.
• Identifies payer denial trends, triages discrepancies, ongoing medical necessity, coding, or service issues, and collaborates or escalates appropriately for resolution.
• Collaborates internally to provide educational opportunities derived from common themes discovered through the appeal process in an effort to prevent future denials.
• Tracks key denial data as they relate to departmental metrics and performance. Develops and maintains key metrics report including the identification of trends, action plans, etc.

Attends organizational committees to present data, as required.

• Communicates directly with payer and coordinates meetings with contracting and payers as needed to support appeals process.
• Performs other duties as assigned.

Qualifications

EDUCATION

Two (2) years of college or equivalent with familiarity with medical terminology and anatomy. Knowledge of coding, billing, and the revenue cycle.

Working knowledge of human anatomy and physiology, disease process, demonstrated knowledge of medical terminology and the medical record.

EXPERIENCE

Three to five years of coding and / or billing experience required. Previous experience with governmental and managed care denial / appeal process including familiarity with RAC.

Experience with medical and insurance terminology, CPT, ICD coding structures, and billing forms (UB, 1500). Epic HB billing knowledge preferred.

LICENSURE

Certified Coding Specialist (CCS), Certified Coding Specialist Physician based (CCS-P) certification through the American Health Information Management Association (AHIMA) and / or Certified Professional Coder (CPC) or Certified Outpatient Coder (COC) through American Academy of Professional Coders (AAPC) or similar certification is required, or must be obtained within a year of hire.

SPECIAL SKILLS

In-depth knowledge of documentation elements within the medical record. Expertise in governmental payment policies and regulations including medical necessity, NCCI, OCE, and MUE policies and procedures.

Ability to analyze and resolve coding and medical necessity payer denials through in-depth knowledge of payer policies and appeal procedures.

Previous experience with clinical denials and appeals for all payers is preferred.

YNHHS Requisition ID : 110180

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