Mgr CBO Denials

Overview

The CBO Denials Manager will oversee denials for multiple hospital campuses and all payers. The Manager will have strong knowledge of various types of payer denials, appeals, and underpayment management to ensure denials are appealed and resolved timely. Develop and maintain a structured standardized process for facilitating clinical appeals at all levels. Provide oversight and coordination of denials and processes by communicating directly with staff, clients, auditors, payers, vendors, and all other depts. To resolve denial issues. CBO Denials Manager will actively communicate with internal and external depts. involving denials process improvement initiatives. CBO Denials Manager will comply with rules and regulations set forth by the Medicare program and will adhere to HHS policy and procedures regarding claim denials.

Responsibilities

Key Responsibilities and Essential Functions• Develop and maintain a structured standardized process for denials.• Manage time and attendance for staff.• Trains or manages training of employees. Updates and maintains team specific training agenda utilized as a guide for all staff including new hires during the orientation/provisional period.• Provide oversight and coordination of denials by communicating directly with clients, auditors, payers, vendors, and any internal and external depts. and leadership.• Assists staff in critical evaluation skills to determine appropriate escalated action, i.e. Appeal process, as deemed necessary for resolution of denied or unpaid claims. Educates staff to have understanding of the process.• Maintains oversight of deadlines and timelines for appeals at all levels.• Works with team members on the appeals, denials, and underpayment variance.• Reviews denials to resolve billing issues, identify payer/code trends, and attempt to reverse erroneous claim rejections. Notifies and corrects system provisioning for appropriate staff review.• Provide on-going education and support to staff.• Successfully manage the appeals process within the designated time frame.• Coordinate appropriate status determinations using InterQual, Milliman Clinical Guidelines (MCG), payer contracts, and CMS guidelines.• Generate appropriate appeal resolution communication to team members and provider in accordance with company and payer policies.• Request additional information from providers, as appropriate, to facilitate timely appeals.• Collaborates with all and any needed departments both internal and external. Notifies and keeps direct manager updated.• Ensure compliance with HIPAA regulations, to include confidentiality, as required by State and Federal Laws.• Identify denial patterns and escalate to direct manager and Upper Leadership as appropriate with sufficient information for additional follow up, and/or root cause resolution.• Make recommendations for additions/revisions/deletions to work queues and claim edits to improve efficiency and reduce denials.• Review payer communications, identifying risk for loss reimbursement related to medical policies and prior authorizations requirements; escalates potential issues to clinical stakeholders, managed care contracting, and Revenue Cycle leadership as appropriate• Performs other duties as assigned by Management.

 

Qualifications

Education Required• High School Diploma/GED required

Education Preferred• Prefer bachelors or associates degree from an accredited college with some applicable college courses.

License, Certification and/or Registration• Certification Preferred: Certified Medical Billing Specialist (CMBS), Certified Patient Account Rep (CPAR), or Certified Revenue Cycle Rep (CRCR)• Prefer applicant with certification in coding, hospital and/or physician office management courses.

Experience• 3 to 5 years working experience of Hospital or Physician office billing and collection processes with positive outcomes- strongly preferred.• At least 1 year of supervisory experience- strongly preferred.• Proven, applicable experience of working with other individuals, teams, vendors, or management to resolve accounts with positive outcomes- strongly preferred.

Additional Skills/Abilities• Must have knowledge of EXCEL and WORD.• Experience in managing and appealing denials.• Experience with medical and insurance terminology, CPT, ICD coding and billing UB, 1500 claims. Knowledge of InterQual and/or Milliman Care Guidelines (MCG) is strongly preferred.• Knowledge of Medicare, Medicaid and third-party reimbursement methodologies• Effective communication skills verbally and written with internal Hospital departments, Physician Offices, Patient, and Insurance payers.• Must be able to effectively manage a large volume of accounts while maintaining a high accuracy and positive outcomes.• Analytical, creative, and interpersonal skills are essential.• Ability to make good judgments in demanding situations.• Ability to react to frequent changes in duties and volume of work.• Strong organizational skills.