Manager Clinical Denials

University of Texas Southwestern Medical Center Dallas, TX
Department: 700655 - MSRDP Physn Bill & Supp

Full/Part Time/PRN: Day Job

Regular/Temporary: Regular

Schedule: Full-time

Security

This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information

Salary

Salary Negotiable

Experience and Education

High school diploma or equivalent (Bachelor's degree preferred) and 7 years professional revenue cycle working experience, including: 4 years medicine, ancillary, or surgical coding; 1 year clinical and or technical denials management/ prevention; and 3 years progressive management in health care administration, physician group practice, and/or claims processing is required. Manager experience must include producing positive results in a 100% metric driven work environment. Advanced degree(s) (Bachelors, Masters) may be considered in lieu of experience.

Professional Coding Certification required (e.g., CPC, CCS-P). CPB (preferred).

The Manager Clinical Denials is responsible for denials management in regards to coding issues. It requires a person that is CPC certified and has follow-up experience. This position must be accountable and responsible for the clinical denial prevention and management program for either the centralized Medicine and Ancillary or Surgical revenue cycles in a collections metric driven environment. Monitor appeal effectiveness and denial prevention efforts by reviewing Epic work queues and reports, MS Excel remit code level reports, and the Epic staff note payment percentage report. Monitors Epic follow-up work queue automation rules to ensure they are functioning correctly. Conducts analysis of denials and denial trends by type and payor. Monitors payor reimbursement policies to prevent future claim denials. Actively participates in the University Edit Administration Committee

Job Duties

* Accountable and responsible for the clinical denial prevention and management program for either the centralized Medicine and Ancillary or Surgical revenue cycles in a collections metric driven environment.

* Monitor appeal effectiveness and denial prevention efforts by reviewing Epic work queues and reports, MS Excel remit code level reports, and the Epic staff note payment percentage report.

* Monitors Epic follow-up work queue automation rules to ensure they are functioning correctly and or if adjustments or new rules need to be written.

* Conducts analysis of denials and denial trends by type and payor.

* Monitors payor reimbursement policies to prevent future claim denials and or internal denial routing for correct and prompt resolution.

* Coordinates, with supervisor, the appeals process for all balances deemed appropriate.

* Facilitates payor denials related communication with revenue cycle operations staff, clinical operations staff, and Revenue Cycle Operations management.

* Works with staff to identify the root cause of denials and to implement effective strategies and process improvements, to reduce costly delays in payment.

* Assures prompt action is taken on denials by coordinating with supervisor/staff to create written and/or verbal clinical appeals with payers.

* Formulates letters of appeal. Ensuring they include relevant and effective clinical documentation from the medical record; supported by current industry clinical guidelines, evidence based medicine, local and national medical management standards and clinical protocols.

* Actively participates in the University Edit Administration Committee to ensure accountability for denials reduction performance, and ensures compliance with all governmental regulations and non-governmental guidelines.

* Maintains and applies an excellent understanding of physician reimbursement policy and coding methodologies including, but not limited to AMA, CMS and specialty societies to ensure physician practice revenue integrity and compliant documentation and coding.

UTSouthwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. In accordance with federal and state law, the University prohibits unlawful discrimination, including harassment, on the basis of: race; color; religion; national origin; sex; including sexual harassment; age; disability; genetic information; citizenship status; and protected veteran status. In addition, it is UTSouthwestern policy to prohibit discrimination on the basis of sexual orientation, gender identity, or gender expression.

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