Rush University Medical Center  Denial Appeal Specialist in Chicago, Illinois

Job Title: Denial Appeal Specialist

Department: HB Govermental Billing/Collections

Shift: 1st

Full/Part: Active Regular FT (72 to 80 hours per pay period)

Specialty: Billing/Collecting

Job Number: 2018-3705

Job Description:

Denial Appeal Specialist

Position Highlights:

This position reviews initial clinical denials, document appeals for clinical inpatient denials, conducts appeals as appropriate. Track denial outcomes, identify trends and work to prevent future clinical denials by communicating with clinical and revenue cycle leadership about denial root causes and help develop education and process changes. Exemplifies the Rush mission, vision and values and acts in accordance with Rush policies and procedures.

Position Responsibilities:

  • Reviews clinical denials and initiate appeals process.

  • Conducts medical necessity reviews and prepares any required clinical documentation summaries to accompany appeals.

  • Communicates with payer representatives or other stakeholders to ensure appeal has resulted in an overturned denial or has escalated through the proper channels.

  • Monitors and follows up on appeals throughout entire process.

  • Assist Utilization Management on implementing a strong process that will help prevent claim denials and lodge successful requests for appeals.

  • Works collaboratively with Denial Analyst on reporting trends and root causes.

  • Attends Denial Meetings.

  • Maintains accurate, clear, timely documentation related to denied cases.

  • Participates in the policy and procedure decision-making process and adheres to all policies and procedures set forth by the Care Management Department and Rush University Medical Center.

  • Performs appeal case review functions including reviewing denied governmental and non-governmental cases for appeal ability.

  • Coordinates clinical appeals process for RUMC and ROPH including payer contacts, OIG/RAC correspondence, summary documentation of status and action taken, follow-up activities, and internal tracking.

  • Maintains accurate, clear, timely documentation of processes. Manages Care Management denial management database. Tabulates the financial gains of the position and opportunities for improvement.

  • Develops, implements and evaluates processes to ensure accurate and timely collection of information. Identifies billing-related issues and works with the payers, Care Management, Finance, physicians and staff to resolve issues in a timely manner.

  • Identifies denial avoidance process improvements. Provides results reporting and communication. Tracks outcomes, shares results, identifies trends, and presents strategies.

  • Resolves denial and appeal complaints from patients, insurance companies and other offices for hospital-related services.

  • Works with and educates staff, physicians, and payers on reimbursement issues, clinical protocols/criteria, insurance plan changes, regulations and process improvements.

  • Responds to patient and family inquiries regarding denials.

  • Serves as a resource, maintains expertise and continues self-education by attending applicable conferences, workshops and interdisciplinary meetings.

  • Utilizes local, regional and national forums to continuously enhance expertise and knowledge base.

  • Participates in applicable professional organizations and committees.

Position Qualifications Include:

  • High Diploma or GED.

  • Certified Medical Coder.

  • 2 years of experience with hospital denial or case management or nurse audit.

  • Knowledge of hospital revenue cycle and compliant coding/billing practices.

  • Knowledge with CMS regulations and guidelines, including but not limited to LCDs and NCDs.

  • Knowledge of Epic applications with focus on Resolute Hospital Billing.

  • Clear and concise verbal and written communication skills.

  • Math skills.

  • Experience multi-tasking.

  • Organized, attentive to details, and self-motivated.

  • Ability to interpret medical policies from major payers.

Company Highlights:

  • Ranked among the top academic medical centers in the country, Rush University Medical Center is an outstanding place to enhance your career. Everything we do centers on one goal: improving patient care.

  • Rush is an academic health system comprising Rush University Medical Center, Rush Copley Medical Center and Rush Oak Park Hospital.

  • Leading academic medical center, acute care hospital w/ 664 licensed beds.

  • Ranked among the top 20 best places to work in healthcare by Indeed.

Rush is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, and other legally protected characteristics.