AR Appeals Denials Specialist-Hybrid (Katy, TX)

This is a hybrid position-location 701. S Fry Katy, TX 77450

Looking for candidates with the following:

• Appeals with hospital accounts
• Epic experience is a plus
• Government Advantage Payers
• Hospital Revenue Cycle experience

At Houston Methodist, the Accounts Receivable (AR) Appeals Denials Specialist position is responsible for reviewing accounts which have been denied or underpaid by third party payors, resolving the issues resulting in denial/underpayment, and submitting formal appeals with the goal of maximizing reimbursement for the services provided by Houston Methodist. This position is responsible for understanding healthcare contracting terms and requirements in order to address underpayments and denials in accordance with regulatory and contractual obligations. This includes contract content review, application of appropriate contract terms and fee schedule(s), and a thorough understanding of the requirements of the Government and Non-Government payment policies and payer contracts. Additionally, this position identifies accounts with payment review opportunities, appropriately communicating with payors and/or Managed Care regarding contract compliance responsibilities and resolving reimbursement discrepancies. This position must be able to articulate an argument or justification for additional reimbursement to the payor for services provided. This position works both independently and as a part of the Accounts Receivable Team, as well as with other teams within revenue cycle and throughout the health system.

PEOPLE ESSENTIAL FUNCTIONS

• Promotes a positive work environment and contributes to a dynamic team focused work unit that actively helps one another to achieve optimal department and organizational results.

• Strikes a balance between maintaining trustful relationships and ensuring timely payments. Exhibits professionalism and trustworthiness.

SERVICE ESSENTIAL FUNCTIONS

• Reviews accounts, takes appropriate action, and documents per departmental standards. Ensures the reason for denial (clinical, administrative, or technical) is clearly stated on the payment documentation. Handles technical issues and forwards clinical and administrative issues to the appropriate group for review.

• Confers with Billers, as necessary, to obtain additional information/clarification and requests rebills as needed.

• Researches denials and determines if there is a legitimate case for overturning the denial, in accordance with the payor's medical policy or the contract. Drafts and submits appeals using a sound argument for denials that have a reasonable chance of being overturned.

• Informs manager of payor trends or any problems or changes in payor requirements, including any barriers or obstacles.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Provides clear and concise documentation of every action taken on an account in the system collection notes. Provides balance breakdown to document the status of next responsible party (i.e., primary, secondary payor, patient balance, or credit balance).

• Identifies accounts for advanced due diligence steps or legal placement in accordance with department policy and procedure. Effectively manages inventory in accordance with departmental standards.

• Utilizes contracting modeling and notifies manager if incorrect payments/contractuals are being calculated.

• Meets or exceeds stated Performance Indicator Expectations (e.g., productivity, account reviews, agings) as demonstrated on weekly Key Performance Indicator.

FINANCE ESSENTIAL FUNCTIONS

• Follows up on assigned delinquent insurance claims. Ensures maximization of collection dollars from insurance companies in accordance with the respective contract and/or Houston Methodist financial arrangement.

• Analyzes accounts for errors, adjustments and credits, issuing corrected entries when necessary. Updates account information accordingly. Follows levels of authority for posting adjustments, refunds, and contractual allowances.

• Uses resources effectively and efficiently. Organizes time effectively, minimizing incidental overtime, and sets priorities. Utilizes time between heavy workloads efficiently and helps other team members.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Stays current on various payors and industry trends. Seeks opportunities to expand learning beyond baseline competencies with a focus on continual development.

• Generates and communicates new ideas and suggestions that will improve quality or service. Demonstrates adaptability and flexibility in the face of changing demands.

This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.

EDUCATION

• Bachelor's degree (preferably in business administration, finance, healthcare administration, or related discipline) or additional four years of experience (in addition to the minimum experience requirements listed below) in lieu of degree

WORK EXPERIENCE

• Three years of experience working in contract compliance or revenue cycle environment