The Clinical Appeals Specialist serves to organize, negotiate, and communicate clinical claim denials with internal clinical staff and the financial services department, as well as external claims representatives of a variety of insurers. In order to optimize the recovery of reimbursement from denied claims and, thereby, enhance the overall financial outcome for CHRISTUS Health, this position manages the claims denial database and provides technical support activities for clinical appeals/audits, including timely medical record releases. This requires timely, articulate direct communication to all stakeholders, with appropriate supporting clinical documentation for unique payer utilization and claims submission requirements. The incumbent supports this activity with the CHRISTUS Health facilities and the Clinical Appeals Nurses. This position further enables financial recovery reporting for CHRISTUS Health leaders and support for contract negotiation with payers, especially managed care companies.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Effectively manages day by organizing and prioritizing.
Properly identify denial type (audit vs. denial) and categorize to ensure appropriate management of audits and denial appeals.
Obtains necessary information needed to complete an audit/appeal; ensures timely responses and updates in all required systems.
Researches and evaluates insurance payments and correspondence for accuracy.
Assures the denials database is accurate and remains up-to-date; organize and prioritize data input into this system.
Keeps up-to-date reports and notates any trends pertaining to insurance denials.
Calls insurance companies to inquire about EOBs, denial letters, denial reasons, and payments.
Prepare the appeals for clinical review and be responsible for recording and tracking on a regular basis.
Work in conjunction with Patient Financial Services (PFS) to reconcile denial payments and recoupments in the denial database.
Collaborate closely with the payers, vendors, Appeals Nurses, Coding Integrity Team, and regional Audit Coordinators to assure they are informed regarding appeal decisions, denials and recoupments.
Provides feedback to members of the healthcare team (health information management (HIM), case management, PFS, etc.) regarding charging, documentation, patient status and coding issues so changes can be made to prevent future revenue risk.
Works with corporate department and leaders, communicating information regarding payer activities and outcomes as needed on specific cases.
Monitors and assures compliance with all policies, procedures and standards as promulgated by state and federal agencies, the facilities, and other regulatory entities.
Coordinates clinical appeals process for payer contacts, OIG/RAC correspondence, summary documentation of status and action taken, follow-up activities, and internal tracking.
Has regular and predictable attendance.
Bachelor's Degree or equivalent years of relevant work experience preferred.
A minimum of (5) years of healthcare customer service, claims, denials, appeals, compliance or related experience is required.
Ability to communicate with multiple levels in the organization (e.g. managers, clinical, and support staff).
Excellent organizational skills including effective time management, priority setting and process improvement.
Strong background in the healthcare field is required.
Understands the difference in billing, collections, payments, and refunds for governmental, managed care, and commercial payers.
Possess an understanding of accounts receivables and claim denials.
Knowledgeable and/or previous experience in Medicare Recovery Audits and managed care audit processes.
Clear concise verbal and written communication skills.
Time management/Decision making/Problem Solving.
Able to work independently and within team environment.
Computer experience in Microsoft Office (Word and Excel).
Knowledge of general medical terminology, CPT, ICD-9 and ICD-10 coding
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.