Position Summary:
The Front-End Denials Management Coordinator is responsible for managing the scheduling and coordination of peer-to-peer discussions between healthcare providers and payer medical directors upon receipt of front-end denials (e.g. medical necessity, status). This role plays a key part in the denial management process by ensuring timely and effective communication to address denied admissions and secure revenue.
Department Summary:
Utilization Management department oversees the process of evaluating and monitoring the medical necessity, appropriateness, and efficiency of treatments, procedures, and services provided to hospitalized patients.
Job Qualifications:
- High School Diploma or equivalent
- Understanding of Medical Terminology
- Knowledge of health care insurance denial practices and compliance, preferred
- Strong communication and interpersonal skills
- Excellent organizational and time management skills
- Ability to work independently and as part of a team
- Proficiency in using computer systems, programs and applications (e.g. EMR systems, Microsoft Office Suite, Teams)
Job Skills:
- Ability to interact with physicians, employees, and others in a professional manner
- Ability to receive, understand, and implement direction from supervision and management
- Ability to effectively function within the framework of department and organizational policies and procedures.
- Detail oriented
- Communicate effectively
- Adaptability to changing work environment or needs
- Other duties as assigned by the Director or designee.
Responsibilities & Expectations:
- Case Preparation: Gathering and organizing necessary clinical documentation and information to support the peer-to-peer discussion. This includes pulling payer criteria from their website or making a request for it to be provided and conducting a brief review to confirm that admission criteria is met or that there are other relevant factors of the clinical episode that may support the Inpatient admission.
- Scheduling Peer-to-Peer Calls: Contacting payers to schedule and confirm peer-to-peer calls between healthcare providers and payer medical directors to discuss denied episodes of care (e.g. status).
- Documentation: Accurately documenting information obtained from payer calls and updating account statuses in relevant systems.
- Communication: Acting as a liaison between healthcare providers, payers, and internal stakeholders to facilitate communication and coordinate schedules.
- Problem-Solving: Identifying and resolving scheduling conflicts and escalating issues as needed to ensure timely peer-to-peer discussions.
- Process Improvement: identifying potential delas and trends related to payer denials and suggesting improvements to the denials management process.
- Compliance: Ensuring compliance with state and federal laws and regulations related to denial management and peer-to-peer reviews.
- Ability to multitask phone calls, emails, and faxes.
- Keep up to date on payer policies.
Working Conditions:
- Work eight hours a day. This position requires daily coverage, Monday - Friday
- Hybrid/WFH schedule may be available
- Must be in good physical and mental health and maintain an excellent attendance record
- Must adhere to hospital policies and procedures
- Must fulfill position description requirements
- Is subject to frequent interruptions during performance of duties
- Must be able to utilize computer/word processing
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, disability, gender identity, sexual orientation or protected veteran status.
Hazardous Exposure Category:
Category III- Includes tasks that involve no exposure to blood, body fluids, or tissues and Category I tasks are not a condition of employment. The normal work routine involves no exposure to blood; body fluids or tissues (although situations can be imagined or hypothesized under which anyone anywhere might encounter potential exposure to body fluids.) Persons who perform these duties are not called upon as part of their employment to perform or assist in emergency care or first aid or to be potentially exposed in some other way.
