Lead Denial Specialist

MINIMUM QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. High School diploma or equivalent.
EXPERIENCE:
1. Three (3) years' experience in a physician/hospital scheduling and registration (including obtaining prior authorizations, admissions, and insurance verifications) or business office environment.

CORE JOB DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Assists supervisor with employee selections process, coordinates and facilitates training for new employees, provides input to supervisor in regards to performance evaluation/competencies, communicates potential issues to supervisor as it relates to employee performance and training, and assists staff with resolution of problems in a timely manner.
2. Oversees day to day operations of Centralized scheduling department.
3. Schedules employees according to needs of department. Handles call offs.
4. Schedules outpatient procedures via telephone with patients and offices in a courteous, professional manner.
5. Coordinates multiple procedure patients have to ensure they are scheduled on the same day or within an appropriate time frame.
6. Provides patients and offices with accurate instructions regarding the schedule procedure (i.e. NPO, arrival time, where to arrive, etc.)
7. Checks order documents of completeness. Validate orders against scheduled services. Inputs outside orders into EPIC.
8. Clearly documents activities and actions take on accounts, which includes but not limited to authorization, communication with patients, staff and other departments.
9. Maintains scheduling and registration accuracy threshold of 95% as identified in audit processing.
10. Performs prior authorization process by performing medical review and entering authorizations into system.
11. Works and assists with the billing department in researching and resolving rejected, incorrectly paid, and denied claims as requested.
12. Obtains demographic/billing/insurance information from patient/family/legal guardian and correctly enters into the scheduling and registration/billing systems for service and claim processing.
13. Verifies insurance, validates pre-cert/pre-auth information after completion of insurance verification and record results in system. Preforms other insurance related functions as required or necessary.
14. Completes Medicare Secondary Payer forms, where applicable. Completes medical necessity screening. Verify medical necessity for applicable payer service.
15. Cancels or reschedules patients in accordance with hospital workflows.
16. Exercises proper stewardship through the appropriate us of supplies, equipment, and time
17. Follows hospital, state, and federal guidelines for ensuring safe environment for workers, patients and public. Ensures compliance by staff to hospital, governmental and insurance regulations.
18. Actively participates in in-services, staff meeting, continuing education courses, hospital wide committees, and other meetings as needed or required. May be scheduled to work various shifts based on departmental and patient needs.
19. Participates in the processes to assess and improve the services provided and compliance with regulatory requirements. Reports results assessment and improvement processes to the appropriate administrative level.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Must meet Department of Labor's MEDIUM duty standard (MEDIUM WORK-Exerting up to 50 pounds of force occasionally, and/or up to 20 pounds of force frequently, and/or up to 10 pounds of force constantly).
2. Able to bend, stoop, reach and be capable of normal rotation, standing and walking for and 8-10 hour shift.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. May be required to travel between facilities/buildings.
2. May be scheduled to work various shifts based on departmental and patient needs.

SKILLS AND ABILITIES:

1. Strong communication skills.
2. Excellent customer service and telephone etiquette.
3. Use a computer keyboard, monitor, and mouse.
4. Knowledge in admissions, registration, and insurance verification.
5. Working knowledge of office equipment and computers.
6. Must demonstrate the ability to use tact and diplomacy in dealing with others.
7. Knowledge of healthcare insurance plans.
8. Knowledge of hospital clinical departments and service protocols.
9. Knowledge of hospital payment plan guideline.
10. Knowledge of healthcare coding practices. Understands and uses applicable CPT and ICD-9 codes.
11. Ability to multi task and perform duties well, while under pressure, while meeting deadlines.

Additional Job Description:

• Research payer denials related to referral, pre-authorization, notifications, medical necessity, non-covered services, and billing resulting in denials and delays in payment
• Responsible for coordinating communications regarding billing information to ensure timely collections of accounts receivables.
• Providing direction and training while focusing and enhancing overall collection performance.
• Prepare reports, presentations, and other written communications.
• Oversee denial prevention by analyzing trends and collaborating to update processes
• Independently write professional appeal letters.
• Submit detailed, customized appeals to payers based on review of medical records.
• Submit retro-authorizations in accordance with payor requirements in response to authorization denials.
• Identify denial patterns and escalate to management as appropriate with sufficient information for additional follow-up, and/or root cause resolution.

Scheduled Weekly Hours:

Shift:

Exempt/Non-Exempt:

Company:

Cost Center:

Address:

Equal Opportunity Employer

West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.