Case Management Denials Coordinator
The Case Management Denials Coordinator assumes responsibility and accountability for continuous research and prevention of denials from all payers. This role will create structure for resolution of root cause denial trends by continuously working to identify opportunities for workflow improvements and root cause breakdowns resulting in payer denials. This position will collaborate with individuals across revenue cycle to remove barriers and initiate workflow improvements. Responsibilities will include assuming ownership of denial reporting generation, distribution, and education of end users.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
- Consistently supports and communicates the Mission, Vision and Values of St. Joseph Medical Center.
2. Follows the St. Joseph Medical Center Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
3. Promotes a culture of safety for patients and employees through proper identification, proper reporting, documentation and prevention of medical errors in a non-punitive environment.
4. Requires extensive knowledge of the revenue cycle process, which includes patient access, utilization review, charge capture, HIM and patient accounting.
5. Requires advanced analytical and critical thinking skills necessary to determine root cause of denial which includes patient access, case management, utilization review, HIM and patient accounting processes and variances in processes.
6. Requires knowledge of rules and regulations pertaining to hospital reimbursement.
7. Comprehensive knowledge of Utilization Review levels of care and observation status.
8. Requires strong data analytics skills.
9. Requires familiarity with managed care principles.
10. Requires the interpersonal skills necessary to maintain effective working relationships with staff, physicians, review agencies, and insurance companies.
11. Requires effective communication skills (both verbal and written) necessary to prepare reports and provide education to staff and physicians regarding the revenue cycle process.
12. Demonstrates the ability to be self-motivated and detail oriented.
13. Demonstrates a working knowledge of the Hospital’s computer systems and proficiency in data entry, word processing, and spreadsheets.
14. Demonstrates commitment to service excellence in all interactions and in performing all job responsibilities.
- l Excellent time management skills to develop organized work processes in high volume environment with rapidly changing priorities.
- Promotes teamwork and to effective function in teams.
- Interacts effectively with key internal and external constituent’s using collaboration and customer service skills that promote excellence.
- Performs all other duties as assigned including projects for the Director using Microsoft Office programs including Excel spread sheets, Power Point, Word, and other programs.
- Maintains personal initial and annual mandatory and optional education to meet deadlines and improve skills, meet HIPAA and Compliance guidelines.
- Sets an example to all SJMC staff by demonstrating caring and courtesy and meeting all conduct and dress code standards.
- Supportive of the compliance program set forth by Steward Health Care and demonstrated by:
- Upholds the Steward Health Care Standards of Conduct and Corporate Compliance.
- Adheres to and helps to enforce all compliance policies relevant to his/her area.
- Assures timely compliance education as requested by the Regional Compliance & Safety Officer and/or through corporate initiatives.
MINIMUM KNOWLEDGE, SKILLS AND ABILITIES REQUIRED:
- Significant experience in the healthcare field is required including a minimum of five years as a clinical nurse in an acute care setting. In addition, having three to five years of experience in case management, discharge planning, and/or utilization review is preferred.
- Current State of Texas Registered Nurse License
EDUCATION & TRAINING:
- Bachelor’s degree, Master’s preferred.
- Technical, critical thinking, and interpersonal skills relevant to area in order to effectively communicate with physicians, health team members, patients and families, other health care professional and community agencies.
- Extensive knowledge of the revenue cycle process.
- Knowledge of InterQual Level of Care and Milliman Criteria
- Knowledge of third party payor regulations related to utilization.
- Knowledge of regulatory requirements.
- Strong analytical and problem solving skills.
- Deductive reasoning skills, being able to assess what the problem is and then take to the next steps needed for resolution.
- The ability to work with others in a team environment.
- Strong communication skills both verbal and written.
- The ability to be proactive.
- The ability to analyze data and identify trends in order to prevent errors from reoccurring that lead to payor denials.
- The ability to present in front of others the denial findings, in order to facilitate the reduction of denials.
- Ability to prioritize work with minimal supervision, in order to independently carry out the duties of the position.
- Proficient in Microsoft Office (especially Word, Excel, and PowerPoint). Computer Literacy and ability to become proficient in SJMC and IASIS computer programs to perform requirements of the job.