Denials Coordinator - AHS Vista LLC
Waukegan, IL
About the Job
The Denials Coordinator assumes responsibility and accountability for continuous research and prevention of denials from all payers, as well as appeals of all accounts reviewed and deemed appropriate for appeal. The Coordinator will create a structure for resolution of root cause denial trends by continuously working to identify opportunities for workflow improvements.
Responsibilities:
- Research clinical records, appropriate insurance regulations and history of claim to determine next step
- Monitor day to day compliance of appeal decision time frames and collaborate with other departments to ensure timely resolution of issues or appeals.
- Review clinical and medical records for completeness and determine administrative or clinical appeal. Assign reviews to physician advisors and medical directors for those requiring medical necessity reviews.
- Coordinate first, second and third level appeals.
- Consults with managers on problem cases and interfaces with case managers, clinical supervisors, account managers and other personnel in resolving denial and appeal questions.
- Ensure proper documentation of all denials into billing systems to include tracking outcome for reporting to appropriate parties
- Manage appeals to ensure timely submissions
- Monitor volume of appeals in order to engage additional resources when needed.
- Form professional relationships with payer appeals and utilization departments
- Enter all data related to appeals and case reviews into a database
- Prepare and present information on appeals to applicable committees and personnel as requested.
- Prepare for and complete appeals audits.
- Monitor and report QI (Quality Improvement) activities of appeals department.
- Demonstrate ability to draft professional letter by incorporating supporting documents, policies and statutes.
- Audit, reconcile, and bill observation charges daily.
- Transition of Care Coordinator
Requirements:
- Bachelor's Degree in Nursing preferred or actively pursuing.
- Licensed as a Nurse in the State of IL.
- Graduate of an accredited nursing school.
Source : AHS Vista LLC