Denials Prevention Coordinator

The Denial Prevention Coordinator (DPC) is responsible for working with the Revenue Cycle Manager, Plutus, and the rest of the RCM team on denials and AR management for the department as defined by the Revenue Cycle Manager. In addition, the DPC will work with the DPS to resolve outstanding denials in a timely manner by tracking outcomes of appeals, communicating prevention strategies within CND, providing monthly reports on all activity by payer, utilize data to track, trend, and analyze the root cause of denials, and collaborate with other CND departments to resolve identified opportunities through coding, training, and process changes.

Job Responsibilities:

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  Research payer denials related to referral, pre-authorization, eligibility/registration, notifications, medical necessity, non-covered services, and billing resulting in denials and delays in payment.
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  Submit detailed, customized appeals to payers based on review of medical records and in accordance with Medicare, Medicaid, and third-party guidelines as well as CND's policies and procedures within a timely and accurate manner.
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  Contact insurance companies to follow up on appealed claims. Hold insurance company accountable for timely resolution of all appeals submitted.
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  Identify and communicate all denial trends and provide education of steps to prevent future avoidable denials.
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  Process and follow up on payer denials, rebilling, or submitting adjustments as needed.
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  Manage outstanding Account Receivables related to denials.
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  Organize the workflow to ensure that denials are worked according to departmental policy and standards.
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  Manage correspondence and any medical records requests as defined within department workflow procedure to ensure timeliness and accuracy of response.
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  Submit retro-authorizations in accordance with payor requirements in response to authorization denials.
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  Provide monthly reports on all activity by payer.
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  Utilize data to track, trend, and analyze the root cause of denials, and collaborate with other CND departments to resolve identified opportunities through coding, training, and process changes.
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  Ensure compliance with official guidelines (ICD-10-CM, AHA Coding Clinic, AMA CPT Assistant and Guidelines), AHIMA Standards of Ethical Coding, and Lifepoint Health Support Center (HSC) policies and procedures.
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  Complete special projects as assigned by manager

Knowledge, Skills & Experience:

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  2-5 years' experience in a medical billing setting with exposure to denials, appeals, insurance collections and related follow-up.
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  Minimum 3+ years' experience in denial management preferred.
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  Experience with laboratory and pathology coding preferred.
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  Knowledge of the current ICD-10 and CPT coding system.
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  Knowledge of business processes, accounting principles, billing practices, and medical terms.
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  Knowledge of Medicare, Medicaid, and commercial insurance.
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  Must have a good working knowledge of explanation of benefits (EOB's) and comprehensive understanding of remittance and remark codes.
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  Requires a high level of problem solving and analytical skills.
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  Ability to multitask.
  
• Familiar with multiple payer requirements for claims processing.
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  Familiarity with Microsoft Office Suite with a focus on Excel and Word.
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  Experience with Salesforce, Waystar, Trizetto, Medisoft, and Quadax a plus.
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  Good communication Skills

Education, Certifications & Licensures:

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  High School diploma or equivalent required.
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  Certified coding certificate required

Special Training:

• Salesforce, Quadax, TriZetto, Waystar

Other:

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  This position is a fully remote position. It may require travel for quarterly meetings in our Scottsdale, AZ headquarters or regional office in Atlanta, GA.