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Denials Coordinator

Company: Ahmc Healthcare Inc.
Location: San Gabriel
Posted on: January 10, 2022

Job Description:

Overview The Denials Coordinator, appeals all denials using MCG Guidelines criteria and medical necessity. Collaboratively works with all members of the revenue cycle team and all types of payers to resolve denials, maximize accurate and timely reimbursement, and perform reimbursement recovery and retention service. Evaluates, tracks and trends denials, and implements denial prevention programs. Educate clinical care providers to improve the documentation of all conditions, treatments, and care plans to reduce denials. Works in collaboration with Case Managers, Physicians, Finance and multidisciplinary teams to ensure compliance with documentation and educates as needed. * Demonstrates Core Values and supports Mission, Vision and Values and Code of Conduct. * Can articulate and demonstrate support for organizational goals, the Mission and Vision of the Institution and the core values. * Assures patient/family rights are respected and fulfills the Medical Center's Patient Safety Philosophy. * Maintains confidentiality of patient information and Medical Center business matters. * Complies with all established policies and procedures. * Meets customer service expectations and AHMC Activities. * Promotes a service culture - Service Excellence Program. * Demonstrates the customer satisfaction standards set for the institution. * Actively participates in ways to prevent customer complaints and dissatisfaction with services. * Focuses attention and actions on what is best for the patient or customer. * Attempts to identify all customer needs and tries to meet and/or exceed expectations. * Interacts with all customers in a caring manner. * Promotes a positive teamwork environment. * Creates closure after interactions. * Communicates effectively in a positive, respectful and concise manner. * Safeguards self/others and physical plant and equipment. * Demonstrates and understands personal and department role in the security, health, life and safety plans. * Demonstrates and understands role in the hazardous materials plan and can access information on MSDSs. * Demonstrates and understands the role in the hospital emergency and disaster plan. * Follows procedures for reporting faulty equipment or service problems.Performance Improvement. * Performance Improvement * Participates in performance improvement activities. * Understands and advocates AHMC initiatives. * Consistently applies infection control policies/practices. * Understands and practices standard precautions for self and others in patient care activities. * Understands and practices appropriate disease-specific isolation. * Meets population/age specific competencies per unit specific addendum. * Attends department specific education/training, in-services, and staff meetings. * Attends mandatory staff meetings/in-services/educational/training activities. * Submits all required paperwork on time. * Attendance and Reliability. * Sick or absent time off does not exceed the facility guidelines as outlined in the Personnel Policy manual. * Provides proper notification of absence or tardiness within established departmental time frames. * Appeal all denials in a timely manner by utilizing MCG Guidelines contract regulations, and solid judgment for all (Medi-Cal, Medicare & Managed Care). * Utilizes denial log to keep track of all denials and the appeal process. * Evaluate, develop and implement strategies for decreasing Denials of all payers. * Interprets regulations and payer contracts to determine optimal reimbursement for the facility. * Liaise with Facility Department Directors such as DPS, Case Management and CBO Directors to review, resolve and streamline all necessary aspects of denials. * Evaluates and determines the education and training needs of the Medical staff, Nursing staff and Department Directors on how to prevent Denials. * Represents hospital in resolving/negotiating facility insurance denials. * Liaise and meet with non-compliant payers to resolve issues relating to underpayments or denials. Work with Corporate Contract Manager to review contracts to ensure appropriate reimbursement. * Establish appropriate systems for measuring Denial Tracking and Trending. * Continued education in current laws that prevent unlawful denials, California Code of Regulations and HMO Compliance. Attend training and develop relevant knowledge and skills, and educates appropriate staff. * Actively participate in all Corporate and Facility based Denials Meeting. * Actively participate in UR and Medical Staff Dept Meetings regarding denials and upcoming audits. * Other responsibilities that the facility and Corporate delegates regarding denials and denials prevention. * Ability to work independently and advise and counsel at corporate and facility based denial meetings. Qualifications * High School Diploma or equivalent minimum * Bachelor's degree in healthcare field preferred * Certified Coding Specialist credentials from AHIMA * A minimum of 3 years coding experience in a hospital Health Information Management Department * Preferred 1 year experience with acute care hospital CDI * Experience in Case Management/Utilization Management preferred. * RN, BSN, RHIA, RHIT, or CCS required * Certified Coding Specialist credentials from AHIMA * Working knowledge of MCG Guidelines. * Knowledge of appeal processes. * Advance knowledge of ICD-10-CM/PCS Official Guidelines for Coding and Reporting * Advance knowledge of AHA Coding Clinic for ICD-10-CM/PCS * Advance knowledge of AHA Coding Clinic for HCPCS * Advance knowledge of HIPAA regulations and to complete work in compliance of these and other standards * Working knowledge of Title XVII and Title XIX. * Working knowledge of reimbursement related to Medicare, Medi-Cal, Capitation, and Managed Care is required. * Ability to work closely with the physicians in order to appeal denial. * Ability to track outcomes and report findings. * Able to problem solve effectively and independently. * Ability to use clinical knowledge to identify potential quality issues, delays in service, post-acute care needs required. * Must have excellent oral and written communication, interpersonal, problem-solving, conflict resolution, presentation, time management, and positive personal influence and negotiation skills. * Must have strong clinical assessment and critical thinking skills necessary to provide utilization review/discharge planning services appropriate to patients with complex medical, emotional and social needs. * Must have the ability to work in a high volume caseload environment and deal effectively with rapidly changing priorities. * Must have excellent communications skills to collaborate with hospital staff and outside entities. * Excellent computer skills with Word, Excel and Power point.

Keywords: Ahmc Healthcare Inc., San Gabriel , Denials Coordinator, Other , San Gabriel, California

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