Clinical Payment Resolution Specialist - PBS-K

POSITION PURPOSE

Responsible for reviewing all post-billed denials (inclusive of clinical denials) for medical necessity and appealing them based upon clinical expertise and clinical judgment within the Hospital and/or Medical Group revenue operations ($3-5B NPR) of a Patient Business Services (PBS) center. Serves as part of a team of clinical payment resolution colleagues at an assigned  PBS location responsible for identifying and determining root causes of clinical denials. Responsible for leveraging clinical knowledge and standard procedures to track appeals through first, second, and subsequent levels, and ensuring timely filing of appeals as required by payers, in addition to promoting departmental awareness of clinical best practices. The position will report directly to the Supervisor Clinical / Coding Payment Resolution.

ESSENTIAL FUNCTIONS

Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, and decisions.

Coordinates denial management processes (Clinical and Administrative/Technical accounts, focusing upon retrospective follow-up and appeal processing) with the objective of appropriately maximizing reimbursement based upon services delivered and ensuring that the claim is paid/settled in the most timely manner possible: 

  • Supports Supervisor Clinical/Coding Payment Resolution with communication and follow-up processes related to rejections, denials and appeals, ensuring that such activities are tracked, trended and reported to key stakeholders across the various impacted departments
  • Coordinates rejection, denial and appeal activities with Ministry Organization (MO) based Utilization Review/Case Management departments;
  • Reviews and understands utilization review and coverage guidelines for multiple payers;
  • Identifies solutions to issues affecting reimbursement as it relates to denial prevention (prospective and concurrent) and provides summary of findings to Supervisor to deliver feedback to Ministry departments
  • Supports the maintenance of a denial management data base, standard report sets, letter template and other key job aids.
  • Serves as a resource contact, providing clinical information as requested by payers.  May facilitate coordination information with payers in order to secure appropriate reimbursement;
  • Supports Supervisor Clinical/Coding Payment Resolution as the liaison to members of the medical staff and other MO colleagues, regarding denial management processes, systems and requirements.  May provide clinical input to Pre-Service staff in order to facilitate authorization approvals;
  • Assists in marketing efforts and the education of physicians, physician office staff and MO colleagues;
  • Establishes checks and balances to ensure PBS and MO-based key performance indicators are accurate and that goals/targets are met, and
  • Supports the development of effective internal controls that promote adherence to applicable local, state, federal laws, and program requirements of accreditation agencies and health plans.

Identifies opportunities for process improvement and participates in the implementation of such as needed. Assists in the design and development of system enhancements while monitoring congruency with process goals and regulatory mandates.

Maintains a strong working relationship with the associated Ministry Payer Strategy team’s in order to ensure proper identification, resolution, and coordination of clinical denials in alignment with payer environment and expected reimbursement  

Provides detailed understanding or aptitude for resolving denials based on patient status, length of stay, level of care, missing pre-certification, or other clinical reasons and constructing warranted appeals for defined populations as directed by the Supervisor Clinical / Coding Payment Resolution,

Interprets data, draws conclusions, and reviews findings with all levels of Payment Resolution Specialist for further review.

Serve as a resource to Payment Resolution Specialists providing guidance and mentorship in achieving positive operational outcomes.

 Keeps abreast of denial trends and in regulations concerning healthcare financing and payer relations through journals and professional continued education programs, seminars, and workshops.

Other duties as needed and assigned by the Supervisor Clinical / Coding Payment Resolution.

Maintains a working knowledge of applicable Federal, State and local laws/regulations; the Trinity Health Integrity and Compliance Program and Code of Conduct; as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.

MINIMUM QUALIFICATIONS

Must possess a demonstrated knowledge of denial management functions.  Registered Nurse and a graduate of an accredited school of nursing plus at least four (4) years of nursing experience, to include two (2) years of utilization review/case management, managed care or comparable patient payment processing experience.  Must have current registration with the state Board of Nursing Examiners or have a temporary permit to practice nursing in the assigned state.

Knowledge of and experience in health care including government payers, applicable federal and state regulations, healthcare financing and managed care.

Knowledge of and experience in case management and utilization management.

Knowledge of insurance and governmental programs, regulations and billing processes (e.g., Medicare, Medicaid, Social Security Disability, Champus, Supplemental Security Income Disability, etc.), managed care contracts and coordination of benefits is required.  Working knowledge of medical terminology, and medical record coding experience (ICD-9, CPT, HCPCS) are highly desirable. 

Customer service background is required.  Working knowledge of computer operations and electronic interfaces is required.  Formal software course training is preferred.

Ability to interact effectively with multidisciplinary teams, including physicians and other clinical professionals internally and externally.

Possesses detailed understanding or aptitude to learn and understand denials resolution based on patient status, length of stay, level of care, missing pre-certification, or other clinical reasons.

Must possess in-depth familiarity with third party billing requirements and regulations, and writing appeals.

Must be comfortable operating in a collaborative, shared leadership environment. 

Must possess a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Trinity Health.

PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONS

This position operates in a typical office environment. The area is well lit, temperature controlled and free from hazards.

Incumbent communicates frequently, in person and over the phone, with people in all locations on product support issues.

Manual dexterity is needed to operate a keyboard. Hearing is needed for extensive telephone and in person communication.

The environment in which the incumbent will work requires the ability to concentrate, meet deadlines, work on several projects at the same time and adapt to interruptions.

Must be able to set and organize own work priorities and adapt to them as they change frequently. Must be able to work concurrently on a variety of tasks/projects in an environment that may be stressful with individuals having diverse personalities and work styles.

Must possess the ability to comply with Trinity Health policies and procedures.