Denials Specialist

Summary

The Denials Specialist reports to the Manager of PFS Denials Management. Under general direction and within established Brown University Health policies and procedures, maximizes reimbursement from contracted payers through analysis, tracking, and trending of denials using available metric denial reports. Responsible for actively supporting the execution of strategic initiatives, process re-design, root cause analysis, metric/report development, and special projects as it relates to denials management.

Executes the appeal process by receiving, assessing, documenting, tracking, analyzing, responding to, and/or resolving appeals with third‑party payers.

Brown University Health employees are expected to successfully role model the organization’s values of Compassion, Accountability, Respect, and Excellence as these values guide our everyday actions with patients, customers, and one another.

In addition to our values, all employees are expected to demonstrate the core success factors that tell us how we work together and how we get things done.

• Instill Trust and Value Differences
• Patient and Community Focus and Collaborate

• Consistently applies the corporate values of respect, honesty and fairness and the constant pursuit of excellence in improving the health status of the people of the region through the provision of customer‑friendly, geographically accessible and high‑value services within the environment of a comprehensive integrated academic health system.
• Evaluates denied accounts sent to the Denials Management Department for review. Assigns denied accounts to appropriate department work queues for resolution. Identifies repetitive issues with the goal of identifying preventative solutions. Runs reports and/or uses work queues to identify accounts not worked in a timely manner and follows up with departments when this occurs.
• Reviews denial database report when denials are posted to correctly categorize provider liable denials, their root cause, and resolution. Performs end‑of‑month reviews of the denial database to identify and report on trends, new issues, areas of opportunity, and any other issues/changes related to the denial report that may be appropriate.
• Responds to departmental concerns about data on their monthly denial reports.
• Develops and maintains a strong working relationship with hospital departments and referring physician offices to collaborate in obtaining information needed for successful appeal/reversal of a denial.
• Maintains current knowledge of state and federal regulations, accreditation and compliance requirements, Brown University Health policies, as well as payer‑specific policies including LCDs and NCDs, and payer contracts with Brown University Health to identify cause of denials.
• Researches payer issues resulting in payment delays, denials, underpayments and processing deficiencies and recommends changes as appropriate. Reviews monthly payer updates, prepares a report of the monthly payer updates to present during the monthly Appeal/Denial meeting.
• Tracks the status of appeals by maintaining well‑organized records to ensure established timelines are met.
• Maintains a strong working relationship with payers to assure claims appeals are processed appropriately.
• Processes necessary Life Chart online adjustments or changes related to appeals as needed, within the scope of job function.
• Continually evaluates workflow and identifies opportunities to improve process for full and complete payment for all hospital services rendered to patients.
• Creates, generates, and maintains ad hoc reports as requested by Manager to assist in the daily operation of the department.
• Participates in staff meetings, councils, quality improvement teams and other such meetings and committees as required.
• Develops and maintains working relationship with Brown University Health affiliate departments as needed to ensure full data exchange.
• Performs other duties as necessary.

• After orientation at the corporate facilities, work is performed based on the following options approved by management and with adherence to a signed…