Identifies potential revenue lost by working through review of denials, comparing clinical information to standard recognized criteria, while identifying policies and procedures that would negatively impact reimbursement for services performed within Geisinger professional services. Develop educational materials and analysis regarding medical necessity and other denials to present to the service lines, physician liaison and payors.
Outlines denials impacting Revenue Management, identifying solutions to problem areas. Provides training ideas and process improvements for all areas of Revenue Management. Responsible for maintaining competency, effective utilization of software systems, submitting information for the maintenance of reporting mechanisms, interfacing with other GHS operational departments, while adhering to Revenue Management policies and procedures. Performs duties to support the goals and objectives of the Revenue Management and the Geisinger Health System.
This position will provide a methodology by which the physician can clarify documentation to alleviate the denials or allow process improvement for policies within each payers system.
Ensures the documentation based on policy needs of clinical documentation as it relates to both professional code assignment. Provides education, as needed or works directly with physician staff and other clinical professionals on documentation dynamics related to Revenue Management processes and denial reduction. Interacts as needed with physician staff and other clinical professionals regarding documentation clarification and optimization. Works directly with other areas within Revenue Management outlining opportunities for process improvement and work flow efficiencies.
Provides support to the Director and the Finance Department in the area of denial, reimbursement and appeal processes.
Reports to the Director A/R Management
MAJOR DUTIES AND RESPONSIBILITIES:
*1. Reviews medical denial cases appropriate for appeal.
*2. Appeals appropriate medical denials to decrease monies lost through external denials.
*3. Researches denials and presents information to identify medical necessity/contractual criteria for appeal.
*4. Remains knowledgeable of medical necessity criteria- specific guideline payer requirements and policies.
*5. Remains knowledgeable of the state and federal appeal processes. Ability to research CMS, as well as all other payer policies and procedures to utilize as supporting documentation for appeal responses.
*6. Submits necessary information to maintain an accurate database of denials.
*7. Tracks and reports changes and delays that effect reimbursement.
*8. Works closely with Professional Insurance Billing and Collections as well as Professional Revenue Enhancement to improve reimbursement.
*9. Demonstrates a strong working knowledge and understanding of federal, state, and other third party billing requirements including HCPCS, ICD9, HIPAA and medical terminology.
*10. Participates in a minimum of forty hours focused on career development of classroom training per year. Assist with the establishment of a training school and provide job specific training for all revenue cycle employees in regards to specific functions and communicate ongoing improvements relative to process improvement and service line development.
*11. Develops and implement the most effective approach for obtaining reimbursement for specific denials and policy processes.
*12. Maintains a good working relationship with all payors and other revenue management departments.
*13. Acts as a resource person for contacts within service lines management and physicians that result in a reduction in denials
*14. Reviews and interprets reports related to documentation improvement initiatives, then applies this information as needed. Communicates and presents, in a formal manner, the results of reports to stakeholders including provider staff and clinic operations.
*15. Maintains good rapport and cooperative relationships. Approaches conflict in a constructive manner. Helps identify problems, offers solutions, and participates in their resolution.
*16. Reviews medical record documentation to support professional billing levels and uses both written and verbal communication to enhance documentation to support services rendered.
*17. Directly obtains clinical performance information, including quality and efficiency. Evaluates and interprets analyses and provides summary reports. Effectively communicates findings with team leaders.
*18. Identifies and compiles data from multiple sources to produce requested analysis to support improvement initiatives. Measures changes and trends.
*19. Works closely with all levels of staff to determine analytic and reporting needs and ensures that requested information is created accurately and in a timely manner.
*20. Reports assigned project progress and activity as required. Maintains communication with team member(s) and leadership.
21. Attends and participates on appropriate workgroups and teams as directed
22. Performs other duties as required or assigned.
*Denotes essential job functions.
COMPETENCIES AND SKILLS:
Demonstrates proficiency with MS Word, Excel, and PowerPoint.
Demonstrates knowledge of coding concepts, guidelines and clinical terminology.
Demonstrates clinical knowledge (anatomy and physiology).
Demonstrates strong interpersonal skills and the ability to develop relationship with service line staff, physicians and operational managers
Demonstrates knowledge of healthcare regulations, including reimbursement and documentation requirements.
Demonstrates public speaking and formal presentation skills.
Demonstrates ability to review complex clinical documentation in a medical record and abstract details to update medical policies with payors
Demonstrates ability to discuss documentation with providers in order to present credible support for overturning denial.
Demonstrates ability to interpret and communicate analytical information in a clear, concise manner.
Demonstrates ability to identify key clinical quality, safety issues and support the development of action plans and analyses from multidisciplinary perspectives.
Demonstrates exceptional ability to work independently and as a team member.
Demonstrates ability to function with minimal supervision.
Demonstrates clinical assessment skills and time management skills.
Demonstrates customer focused interpersonal skills to interact in an effective manner with both professional and non-professional staff as well as payors.
Demonstrates ability to function independently and effectively in a rapidly changing environment as well as the ability to influence and negotiate individual and group decision making processes.
Demonstrates knowledge about standards of coding and applies to denial management
Demonstrates strong organizational skills.
EDUCATION AND/OR EXPERIENCE:
Associates or Bachelor’s degree in business administration, healthcare administration or other related field required.
Minimum of five year experience in performing revenue management functions at GHS or in another setting with a similar size or volume is required. This includes knowledge of the revenue management and/or regulatory requirements as they relate to the hospital billing and collections for all third party insurance payers, revenue enhancement and the cash application component for the various service lines contained within GHS and the revenue management.
Associates or Bachelor’s degree in business administration, nursing, healthcare administration or other related field required.
Minimum of three years of experience with payers, providers, hospitals and physicians and understand the commensurate requirements for facilitating accounts receivable resolution by service line including cash flow, billing, collection, cash application and customer service related issues is required. Plus a minimum of three years clinical experience required.
In lieu of degree, may consider a minimum of eight years of experience with Revenue Management functions at GHS or in another setting with a similar size or volume is required. This includes knowledge of the revenue management and/or regulatory requirements as they relate to the hospital billing and collections for all third party insurance payers, revenue enhancement and the cash application component for the various service lines contained within GHS and the revenue management.
AAHAM or HFMA or other certification understanding Revenue Management processes, preferred. Must be obtained within first year in position.
WORKING CONDITIONS/PHYSICAL DEMANDS:
Work is typically performed in an office environment.
The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.
OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities. KINDNESS: We strive to treat everyone as we would hope to be treated ourselves. EXCELLENCE: We treasure colleagues who humbly strive for excellence. LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow. INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation.
One of the nation’s most innovative health services organizations, Geisinger serves more than 1.5 million patients in Pennsylvania and New Jersey. The system includes 13 hospital campuses, a nearly 600,000-member health plan, two research centers and the Geisinger Commonwealth School of Medicine. A physician-led organization, with approximately 32,000 employees and more than 1,800 employed physicians, Geisinger leverages an estimated $12.7 billion positive annual impact on the Pennsylvania and New Jersey economies. Repeatedly recognized nationally for integration, quality and service, Geisinger has a long-standing commitment to patient care, medical education, research and community service. For more information, visit geisinger.org or connect with us onFacebook, Instagram, LinkedInand Twitter.
** Does not qualify for J-1 waiver. We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.
*Domestic partner benefits not applicable at Geisinger Holy Spirit.
At Geisinger, our innovative ideas are inspired by the communities we serve – like our Fresh Food
Farmacy, a program that delivers life-saving healthy alternatives to patients with diabetes. With additional tools like our MyCode Community Health Initiative, one of the first health system genome sequencing
programs, and our new asthma app suite that we developed in partnership with AstraZeneca, it’s no wonder we’re ranked one of the Top 5 Most Innovative Healthcare Systems by Becker's Hospital Review. We continually work towards continuous improvement in a culture where everyone has a voice and firmly believe that better begins with all of us.
Founded more than 100 years ago, Geisinger serves more than three million residents throughout central, south-central and northeastern Pennsylvania and southern New Jersey. Our physician-led system is comprised of 30,000 employees, including 1,600 employed physicians, and consists of 13 hospital campuses, the Geisinger Health Plan, Geisinger Commonwealth School of Medicine and two research centers.
What you do at Geisinger shapes the future of health and improves lives – for our patients, communities, and you.