Denials Analyst

In collaboration with Revenue Cycle leadership, the Revenue Cycle Denials Analyst will bring a deep understanding of payer denial trends, claims processing strategies, payer policy updates, and accounts receivable resolution tactics. The Denials Analyst supports claims’ denials reductions and increased revenues through process redesign, root cause analysis, and development of metrics and reports. The role must also focus on denial prevention by collaborating with clinical teams, operational partners, the contracting team, and insurance payers. The position facilitates regular reviews in partnership with denials-owning areas, service lines, and the RCO team, IS partners, and Rev Cycle leaders to support the identification of denials issues and develop countermeasures to resolution. This position requires forward-thinking individuals who seek opportunities to streamline workflows and apply technology to improve business processes with strategic goals in mind.

• Denial prevention - Identify denial trends; provide documentation, data/reporting to Revenue Cycle Management and owning area key stakeholders, offer suggestions for process improvement, and develop countermeasures in conjunction with operational areas.

• Regularly tracks and analyzes denial data to identify, recommend, and implement opportunities to secure revenue for the organization; Analyzes and reviews third-party payer denial of medical claims and develops and executes strategies to decrease denials system-wide

• Identifies trends or patterns that impact payment optimization, and collaborates with departments to establish action plans, initiatives, and policies to reverse negative denial patterns

• Researches and analyzes applicable regulatory, coding, and billing rules and educates departments on regulations, processes, and medical necessity requirements

• Identifies revenue opportunities and provides appropriate investigation, follow-up, and resolution; Analyzes trends and inefficiencies in medical center charges and recommends suitable operational improvements in an effort to prevent incorrect payments and denials.

• Complete monthly standard denials reports; Parse and share denial trends and data to operational areas for review on a monthly basis; attend needed follow-up calls for support in operational reviews amongst owning areas.

• Identify and communicate system issues related to denials stemming from billing, edits, rejections, and follow-up work queues with RCO and Billing management

• Independently conduct insightful analysis to investigate trends in denial write-off data to aid in the identification and prioritization of denial prevention initiatives.

• Independently facilitates discovery and design sessions for new complex build activities including new automation use cases or enhancements to existing functionality using best practices for automation design and development

• Assists in the creation of automation design documents to support business decision-making, process streamlining, automation development, and performance improvement to meet business and customer needs

• Support in the submission of complex case reviews and appealing surrounding high-priority denials such as auth, medical necessity, COB, etc.

• Coordinate with Reporting/AQ Analyst to develop, generate, and audit various revenue, financial, statistical, and/or quality reports surrounding the denial prevention area of focus

• Support the development, implementation, and evaluation of existing policies and procedures related to denial management

• Submit optimization tickets with the RCO team and/or Analytics to resolve issues, support in testing and training as necessary

• Support Rev Cycle management in the preparation of denials data and strategic opportunities for an executive-level audience

• While Working with the Application Analysts, will thoroughly test and document system upgrades and software modifications related to Denial Management

• Provide training to AR specialists and other denials accountable owners assisting with denial management

• Serves as an active team member; participates in department and company-wide initiatives; contributes to the overall culture

• Development, monitoring, and follow-up of denial metrics within the revenue cycle

• Develop, maintain, and distribute ad-hoc reports as needed

• Provide support in process improvement initiatives

• Maintain a denials’ issues log of acknowledged opportunities and track and monitor progress Perform other related duties as required

• Maintains tracking documents and dashboards

• Conduct special projects as needed

• Perform other related duties as required

What You Will Need:

• High School Diploma / GED or 3 years of relevant equivalent experience in lieu of diploma / GED.

• 5+ years working within the following sectors: healthcare, insurance, business, finance or customer service.

• Working knowledge can be of the following: insurance claims, billing, coding, follow-up, finance, accounting or customer service related responsibilities.

What Would Be Nice to Have:

• Knowledge of claims, denial management, and healthcare collections  activities

• Epic Hospital/professionals modules preferred in an AR/Follow-up capacity

• Knowledge of payor CARC and RARC codes and denial classes