Denials and Appeals Analyst / 40 hours / Day / BWH Patient Access Services

Admitting Department Appeals Specialist

Under general guidance of Patient Access Services Denial Manager, the Admitting Department Appeals Specialist is responsible for assisting with insurance denials and is expected to adhere to programs, policies and procedures to maximize reimbursement by minimizing denials. Under the supervision of the Patient Access Manager, the Appeals Specialist also monitors Huron and EPIC reports and work queues to ensure timely response to denied cases, prepares and submits appeals, provides follow-up on cases until resolution has been achieved. Reviews appealed cases to assist in the determination of departmental write offs, as appropriate. Cultivates, maintains and enhances relationships with third party payors. The analyst performs all these functions in a manner that complies with standards established by Hospital Administration, Medical Staff and outside regulatory and accreditation agencies.

Principal Duties And Responsibilities :

Operations Management :

• Works toward goals and objectives for departmental denial management.
• Has a sound understanding of the payer rules related to the denials and appeals.
• Communicates directly with payers, Payor Operations, BWF and BWH Case Management, Admitting, Revenue Operations, Central Billing Office and other appropriate hospital and physician staff to coordinate appeal activity if deemed necessary.
• Cultivates, maintains and enhances relationships with third party payors.
• Provides case follow-up on denials until resolution has been achieved.
• Formulates and submits timely, well prepared appeals with supporting clinical information and required data and provides this information to third party administrators (payers).
• Assists in the determination of write offs and analysis provided to the Executive Director for review and approval.
• Reviews Huron and EPIC reporting and documentation to determine the root causes for denials and works to implement action plans to prevent future denials.
• Maintains clear channels of communication for effective problem-solving, as related to denials and troubleshoots routine and non-routine problems and takes appropriate actions to address issues.
• Contributes to team work within and between departments. Attends and participates in related meetings as needed. Provides constructive ideas and suggestions in a positive manner.
• Works collaboratively with co-workers and management to effectively resolve issues that impact departmental or hospital operations in order to increase reimbursement and minimize denials.
• Performs various administrative functions, including, but not limited to, supporting management of payer contractions and contract operations around denials including compiling and summarizing denial data and trends in Excel and Word to support meetings and events.

Program Management :

Computer System Management :

Personnel Management :

Fiscal Management :

Miscellaneous :

Education :

Experience :

Skills / Abilities / Competencies Required :

Working Conditions :

Supervisory Responsibility :

Assist with training of new employees when necessary.

Fiscal Responsibility :

The key to the institution's financial viability lies in the integrity of data collected. The work performed by the Admitting Appeals Specialist is a cornerstone of the institution's reimbursement. This position plays a crucial role in preventing denials through root cause analysis and writing appeal as well assisting with retro-authorizations and analysis.