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Performs functions relative to denial management. Compiles and provides Management with denial reports and evaluates trending. Assist with providing feedback to departments on cause and effect of denials and works on appropriate action plans to reduce denials. Works in conjunction with Coding Department for supporting documentation. Facilitate the RAC implementation and response plan. Develop workflows, policies and procedures and the communication plan to prepare for RAC requests, denials and appeals in accordance with our compliance plan. Evaluates and reports risk and develops workflow redesign if necessary. Promotes and models Customer Service principles in all encounters. Ability to give updates in team meetings for Denial Management and RAC events, develop reports and action plans. Conforms to hospital policies and procedures. Must be able to extract data and utilize Microsoft Excel to provide Denial trending reports and graphs.

NON-EXEMPT

Reviews Denial Management reports and encounters daily and completes follow up, as appropriate.

Establishes priorities, completes monthly statistics report and ensures any backlogs are reported to the Supervisor/Manager.

Identifies and implements needed Denial educational programs for Patient Business Services department and other hospital personnel

Adheres to values, standards, policies and procedures at both hospital and departmental level.

Complies with and exemplifies department established customer service standards.

Receives, analyzes and answer inquiries from associates and co-workers on denial inquires.

Assists in the development of departmental policies and procedures and interprets these policies to staff.

Reviews and reports on Denial Trends by department, Denial Type, and other reporting as needed to Supervisor/Manager and staff with recommendations for improvement.

Coordinates Denial Management meetings, set's agenda, and organizes material for meeting.

Develops and implements a comprehensive reporting dashboard for all identified areas of denials.

Monitors and reports the status of open accounts and all pending appeals to PBS Manager, Director and RAC Committee

Manages all Physician/Hospital requests received from RAC

Develop and maintain a tracking system to ensure that responses to RAC requests occur within established time frames without exception.

Assists in the review of charts to be sent to RAC. Reports out to PBS Director, Physician/Hospital billing Manager, Compliance Officer and Administration information such as the likelihood of denial; dollar amount of account; any identified documentation and reports progress monthly.

Administers the RAC appeal and denial process. Follows appeal and denial process through the entire 5 Levels of appeal until a resolution is made and reports this progress monthly to Compliance and Administration.

Communicates with RAC office, Health Information Management and other Benefis Health System resources when necessary and to ensure smooth workflow.

Works with Patient Business Services Director, Health Information Management Director, Compliance Officer and CFO on guidelines to follow for RAC responses.

Assists clerical staff assigned to RAC functions

Ability to research, interpret and develop recommendations.

Demonstrates fiscal responsibility.

Effectively collects and aggregates data

Effectively performs accurate statistical analysis and compilation of reports to facilitate data review

Formats data in charts and/or graphs with accompanying analysis, summary and findings.

Implements, maintains control of the Hospital's primary compliance system

Assists with preparation and participates with all internal and external audits

Maintains current knowledge of hospital policies and standards as applicable to Medicare Billing Requirements

Knowledge of medical record functions to include general record requirements

Ability to read and interpret state and federal regulations

Ability to pay close attention to detail and follow through with action plans

Other duties as assigned

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.

Professional Requirements:

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.