Combines clinical, business and regulatory knowledge and skill to reduce financial risk and exposure caused by concurrent and retrospective denial of payments for services provided. Collaborates with Physicians, Care Managers, Discharge Planners, Hospital Billing Office and payers to appeal denials. Performs activities related to insuring a denial appeals process that includes measuring denial and appeal activity, monitoring for patterns and trends and escalating issues to Denial Task Force.
DUTIES AND RESPONSIBILITIES:
Manages clinical denials for both inpatient and outpatient cases for Benefis Health System.
Coordinates the submission of appeals to third party payers within allotted timeframes to prevent fiscal penalties.
Manages all Medicare RAC denials and processes each denial following the established framework.
Reviews the medical record and related health information to gather missing supportive documentation to strengthen the appeals process.
Maintains dialogue with payers about disputed claims and maintains documentation of ongoing efforts for each disputed claim.
Responsible for preparation of appeal letters and submission to the third party payer including government payers.
Interfaces with Care Manager, Physicians, Patient Business Office, Patient Access and Medical Records to obtain necessary information as needed to respond to denials.
Accurate and timely Entries for all denial and appeal activity into denial software for tracking.
Utilizes Physician Advisor to interface with Physicians as needed.
Works in conjunction with Hospital Finance Dept. in tracking denials, level of appeal, financial impact of both denial and successful overturned denial decisions.
Generates reports of denial activity on a monthly basis with analysis of data and significant trends to the Manager for Care Management and Denial Task Force.
Submits denial and appeal reports in a timely manner to other committees as required.
Assists in the orientation of new staff regarding the denial and appeals process.
Maintains up to date information from payers and distributes changes to all staff and departments involved in the appeal/denial process.
Maintains up to date knowledge of regulatory requirements as it relates to government payers.
Performs Quality Control checks of utilization review activities.
Demonstrates the ability to deal with pressure to meet deadlines, to be accurate, and to handle constantly changing situations.
Demonstrates the ability to deal with a variety of people, deal with stressful situations, and handle conflict.
Adheres to dress code.
Completes annual educational requirements.
Maintains regulatory requirements.
Wears identification while on duty.
Maintains confidentiality at all times.
Attends department staff meetings as required within the department.
Reports to work on time and as scheduled; completes work in designated time.
Represents the organization in a positive and professional manner.
Actively participates in performance improvement and continuous quality improvement (CQI) activities.
Coordinates efforts in meeting regulatory compliance, federal, state and local regulations and standards
Communicates and complies with the Benefis Health System Mission, Vision and Values as well as the focus statement of the department.
Complies with Benefis Health System Organization Policies and Procedures.
Complies with Health and Safety Standards and Guidelines.
3 to 5 years experience in Denial Management, Care Management or Utilization Review
Associate's degree in nursing required bachelor's degree in Nursing preferred.
As a not-for-profit community health system, Benefis is driven to provide the highest level of care. We serve nearly 230,000 residents across a 15-county region that is bigger than Connecticut, Massachusetts, New Hampshire and Vermont combined. Benefis is the largest non-governmental employer in the Great Falls area, with more than 3,000 employees. Benefis has 530 licensed beds (that includes 146 beds in long-term care, 71 in assisted living and 20 beds at Peace Hospice of Montana) and partners with over 250 area physicians.
Our hospital has been recognized for its exceptional work in quality care by providing a wide range of programs and services to help you live the best life possible. We’re here to help you “Live well.”
Benefis Health System came about when two Christian-based hospitals became one. Our founders believed in providing good care to all in need, and trusted that this would be accomplished. The Benefis name was derived using Latin root words: "Bene-" meaning good, and "fis-" for faith and trust. It’s these same root words that make up such terms as ‘beneficial’ a...nd ‘confidence'. Benefis has been a trusted provider of care for more than 125 years. And our name speaks to our commitment: good care one can put faith in.
Benefis is consistently ranked among America’s top hospitals by the nation’s leading healthcare ratings organizations for a range of services, including cancer care, joint replacement, stroke treatment, wound care and home health.
To learn more about our services, continue looking through our website at WWW.BENEFIS.ORG or call 406.455.5000.