UofL Physicians

  • HIM Appeals Specialist

    Job Locations US-KY-Louisville
    Job ID
    2018-5204
    # of Openings
    3
    Category
    Medical Records
    Department
    UMC-UMC
  • Overview

    This position is responsible for successfully managing all components of post-discharge denials as well as payer and RAC audits. Actively involved in CDMP and work closely with Coding Managers on DRG appeals. Interacts as needed with internal customers to include but not limited to hospital staff, physicians and their offices, and other revenue cycle team members.  Actively participates in department and hospital performance initiatives when needed to ensure ULH success.

    Responsibilities

    • Log appeals correspondence into Appeals Tracking software.
    • Review denials for accuracy, prepare appeal letters, and perform timely follow-up on all unpaid claims for HIM-related denials (i.e., post-discharge medical necessity, DRG validations, retroactive prior authorizations, RACs, and other claim audits).
    • Ensure all timelines are met for additional records requests (ADRs).
    • Obtains all necessary information to expedite the appeal process.
    • Works with payers on HIM-related appeal issues.
    • Maintain overall financial viability for UMC Revenue Cycle through collaboration and effective communication with Care Management, Physicians, Coding, and Patient Financial Services.
    • Perform quantitative and qualitative reviews prior to reporting data trends and outcomes.
    • Prepare reports on post-discharge denials management activity including overturn success rate of appeals for corporate compliance.
    • Attend continuing education workshops, webinars, etc., for coding compliance.
    • Perform other duties as assigned.

    Qualifications

    • High School education or GED required.
    • Must have and maintain one of the following nationally accepted Certified Coding or Nursing Credentials (I.e., RHIT, RHIA, CPC, CPC-H, CCA, CCS, NRCCS, CCS-P, LPN or RN).
    • 3 years of prior coding or clinical nursing experience, preferred.
    • Prior experience working with government and commercial payers, a plus.

    KNOWLEDGE, SKILLS, & ABILITIES

    • Knowledge of medical terminology.
    • Demonstrate excellent organizational, computer, written and oral communication skills.
    • Demonstrate strong Microsoft Office knowledge skills.
    • Must possess working knowledge of InterQual, Milliman Care Guidelines, and Coding Rules and Guidelines.
    • Strong time management and critical thinking skills. Ability to foresee projects from start to finish as well as identify trends in denials management data.

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