Clinical Denials Specialist

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This position is responsible for managing accounts receivable related to denied claims to ensure the financial viability of the WVU Medicine hospitals. This includes but is not limited to, denial investigation, follow-up with insurance companies, billing, auditors and clinics/hospital departments, non-clinical appeal writing, accurate and timely account adjustments all while ensuring compliance with all federal, state, third-party billing regulations and contract agreements. Employs excellent customer service, oral and written communication skills. Works with leadership and other team members to achieve best in class revenue cycle processes.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. High School diploma or equivalent.

EXPERIENCE:

1. One year of training in medical billing, coding, insurance processing, or other related experience.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Associate degree in related field

2. Knowledge and experience with EPIC medical billing

3. Experience with Microsoft Excel/Word

EXPERIENCE:

1. Experience with hospital billing.

CORE 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. Accurately triage and route claims to work queues by maintaining a working knowledge of system hospital/clinic departments, procedures and payer appeal processes and deadlines

2. Follow up with third party payers to clarify payment remit issues, ensure timely appeal receipt/process/resolution; adheres to appropriate procedures and timelines and escalate payer behavior issues to management

3. Utilizes payer portals and payer websites to verify appeal status and conduct account follow-up, contacting payers by telephone when needed

4. Composes administrative, non-clinical appeals as directed by leadership. Organizes and manages appeal letter submissions via mail or other portals.

5. Develops and maintains working knowledge of all federal, state, and local regulations pertaining to hospital billing compliance regulations. 

6. Maintains work queue volumes and productivity within established standards. Adhere to timely filing guidelines for work queue prioritization.

7. Post adjustments as directed or by following department SOP, ensuring accurate and timely processing, and validating based on contract pricing/payer models.

8. Manages and distributes incoming mail in an accurate and timely manner; includes Epic documentation, logging incoming correspondence, uploading to document warehouse and routing mis-directed mail; processes outgoing certified mail.

9. Communicates problems hindering workflow to management in a timely manner; provide suggestions to increase workflow efficiency.

10. Participates in educational programs to meet mandatory requirements and identified needs regarding job and personal growth.

11. Attends department meetings, teleconferences, and webinars as necessary or directed.

12. Provides excellent customer service to patients, employees, vendors, and auditors.

13. Utilizes Microsoft Office or other applications as needed to complete job functions, specific reporting, or project management.

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. Manual dexterity used in operating standard office equipment.

2. Prolonged periods of sitting.

3. May be required to walk to various areas throughout the department or medical complex.  This may require the use of stairs and/or elevators.

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. Business Environment.

SKILLS AND ABILITIES:

1. Basic computer knowledge and ability to operate standard office software.

2. Knowledge of medical terminology preferred.

3. Prior experience with Microsoft Office Suite software applications, including, but not limited to, Word, Excel, Access, Power Point and Outlook is preferred.

4. Good verbal and writing skills.

5. Basic mathematical skills

6. Excellent telephone skills.

7. Ability to type at least 35 WPM preferred.

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Non-Exempt)

Company:

SYSTEM West Virginia University Health System

Cost Center:

661 SYSTEM Clinical Denial Management