Senior Denials Mgmt Specialist

At Houston Methodist, the Senior Denials Management Specialist position is responsible for performing utilization review activities, and monitoring the clinical denial management and appeals process, as applicable, in collaboration with clinical team partners. This position uses sound clinical judgement in the Utilization Management process and knowledge of regulatory requirements to make appropriate decisions and is accountable for reviewing denials for level of care, medical necessity, and as appropriate, DRG recoupments/downgrades, and denials for no authorization. The Senior Denials Management Specialist position communicates clinical information utilizing various resources and skills to reduce significant financial risk and exposure caused by unnecessary services provided. This position facilitates accurate reimbursement and provides feedback for process and workflow opportunities to both operational and clinical stakeholders. The Senior Denials Management Specialist position collaborates with physicians, case managers, and payors to ensure appropriate utilization of medical resources and services based on payor regulations and guidelines and, as appropriate, successfully appeal denials and develop meaningful appeal strategies.

Requirements:

PEOPLE ESSENTIAL FUNCTIONS

• Serves as an educational liaison to clinical staff including physicians/providers and clinical directors, and staff, for payor utilization criteria, interpretation medical policies and local/national coverage determinations and, denial reason and trending as appropriate, Monitors CMS, managed care and payor communications for updates/alerts/releases and functions as a support and educational resource to physicians, case management staff and management.

• Communicates to interprofessional staff and customers, information on, and the need to follow, payor criteria for the use of medical resources and services, and third-party payors to certify days, impeding diagnostic and treatment tests, proactively and concurrently resolving claim delays or denials, as appropriate.

• Contributes to improving employee satisfaction/engagement by serving as a role model, coaching staff in effective verbal, non-verbal and written communication, which includes active listening, and facilitating teamwork with RNs, Case Managers, non-licensed and interprofessional staff.

SERVICE ESSENTIAL FUNCTIONS

• Analyzes submitted information including clinical assessments, treatment plan, regulatory guidelines, medical necessity, and accrediting standards for all requests. Provides clinical support to Case Management staff, others as needed and management for data gathering on medical resource utilization, and, as appropriate, resolution of inpatient denials, as well as other tasks related to reimbursement or denial mitigation.

• Provides communication to providers about regulatory guidelines for clinical content in a readable format and describing decision-making rationale for service requested.

• Facilitates direct admissions and transfers into facility or service to include appropriate level of care and, as appropriate, pay approval in conjunction with Patient Access and/or Bed Management areas. Analyzes medical resource utilization to identify new trends, opportunities, and educational feedback needed. Shares feedback to appropriate nonclinical and clinical service areas, physicians, and Case Management staff.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Uses independent judgment to make decisions in the completion of the hospital work ques, ensuring that state and federal regulations are followed. Assists in the development of corrective action plans.

• Identifies barriers affecting patient progression and avoidable days. Develops effective work plans to why services are unnecessary/denied per regulatory guidelines, recognizing root causes, and finding applicable payor policies as appropriate.

• Monitors appropriate resource utilization, and, as appropriate, continued stay authorization based on standard. Gathers and enters all documentation in Case Management software and maintains accurate statistics on utilization recommendations. Provides to management and senior leadership as needed.

FINANCE ESSENTIAL FUNCTIONS

• Researches denials and referrals for medical necessity and provides a weekly and/or as needed, report to management and, as appropriate, the finance department. Makes recommendations at denial management meetings on processes, root causes, and assists in development of strategies to avoid denials, as appropriate.

• Works with Case Management and appeal staff to ensure denial and/or utilization trending data is accurate, and that all metrics are reported appropriately. Monitors referrals and trends to identify corrective measures needed to prevent inappropriate utilization of medical resources, investigates the validity of the referral, and determines the need for continued resources. As appropriate, monitors recovery of payments and trends to identify corrective measures needed to prevent denials, investigates the validity of the reasons for the denials and determines the need for or feasibility of submitting appeals.

• Facilitates communication with payors and external case managers by documenting days certified, proactively and concurrently resolving any denied days or delays.

• Partners with Case Management leadership, patient access leadership, health information management staff, and clinical operations staff to ensure appropriate level of care, and, as appropriate, payor approval and reduce denials.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Leads, identifies, and acts on opportunities for process improvement for delays and obstacles to discharge. As appropriate, identifies internal system activities that may cause denials and work with stakeholders to mitigate avoidable days and denials.

• Investigates and incorporates evidence-based practices which are presented to shared governance and leadership. Supports change initiatives and adapts to unexpected changes. Completes and updates the individual development plan (IDP) on an on-going basis.

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.

Qualifications:

EDUCATION

• Bachelor's degree or higher from an accredited school of nursing

WORK EXPERIENCE

• Seven years clinical nursing/patient care experience which includes three years in utilization review, case management or equivalent revenue cycle clinical role

• Experience includes writing clinical appeals for medical necessity compliance or level of care for government and nongovernmental payers preferred

LICENSES AND CERTIFICATIONS - REQUIRED

• RN - Registered Nurse - Texas State Licensure -- Compact Licensure - Must obtain permanent Texas license within 60 days (if establishing Texas residency) AND
• Magnet-ANCC Recognized Certification (HM)

KNOWLEDGE, SKILLS, AND ABILITIES

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations

• Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security

• Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles

• Maintains knowledge of Federal, State, and local billing regulations and partners with managed care contracting as needed.

• Maintains knowledge of contracts, payor plans and benefits, billing/follow up procedures

• Strong organizational and problem-solving skill as evidenced by capacity to prioritize multiple tasks and role components

• Working knowledge of Microsoft products including PowerPoint, Word, Excel, and Outlook

• Experience with clinical decision criteria such as InterQual, Milliman, etc.

• Demonstrates strong knowledge of commercial insurance and governmental programs, state and federal regulations and billing processes, managed care contracts and coordination of benefits related to coverage, clinical appeals, and denials to include knowledge of CPT and ICD codes and familiarity with Local Coverage Determination (LCD)/ National Coverage Determination (NCD)

• Competence in writing clinical appeals for medical necessity compliance or level of care for government and nongovernmental payors

• Ability to develop an appeal strategy and facilitate clinical appeals to ensure recovery

SUPPLEMENTAL REQUIREMENTS

WORK ATTIRE

• Uniform No
• Scrubs No
• Business professional Yes
• Other (department approved) No

ON-CALL*
*Note that employees may be required to be on-call during emergencies (ie. DIsaster, Severe Weather Events, etc) regardless of selection below.

• On Call* No

TRAVEL**
**Travel specifications may vary by department**

• May require travel within the Houston Metropolitan area No
• May require travel outside Houston Metropolitan area No