AR Follow Up Denials Specialist - Denial & Appeals Mgmt

Lakeland Regional Health is a leading medical center located in Central Florida. With a legacy spanning over a century, we have been dedicated to serving our community with excellence in healthcare. As the only Provisional Level 1 Trauma center for Polk, Highlands, and Hardee counties, and the second busiest Emergency Department in the US, we are committed to providing high-quality care to our diverse patient population. Our facility is licensed for 910 beds and handles over 200,000 emergency room visits annually, along with 49,000 inpatient admissions, 21,000 surgical cases, 4,000 births, and 101,000 outpatient visits.

Active - Benefit Eligible and Accrues Time Off

Demonstrates commitment to the promises, vision, core purpose/mission and goals of LRMC, modeling the values and culture. Works under the supervision of the PFS Supervisor. The AR Follow and Denials Specialist is responsible for collecting payments for outstanding hospital claims, managing accounts, researching denials, submitting corrected claim requests, submitting appeals, and ensuring payments received are reconciled correctly with emphasis place on HIPAA compliance and in accordance with departmental goals, SOP’s, and contract terms. Responsible for adhering to all Federal regulations and maintaining current knowledge of all Insurance guidelines. Escalates payer denials trends or claims issues to the PFS Leadership Team to address with the payer. Identifies trends, system issues, and potential process improvements to avoid future delays and denials.

People At The Heart Of All We Do

• Fosters an inclusive and engaged environment through teamwork and collaboration.
• Ensures patients and families have the best possible experiences across the continuum of care.
• Communicates appropriately with patients, families, team members, and our community in a manner that treasures all people as uniquely created.
• Safety And Performance Improvement
  • Behaves in a mindful manner focused on self, patient, visitor, and team safety.
  • Demonstrates accountability and commitment to quality work.
  • Participates actively in process improvement and adoption of standard work.
  • Stewardship
  • Demonstrates responsible use of LRH's resources including people, finances, equipment and facilities.
  • Knows and adheres to organizational and department policies and procedures.
  • Standard Work: AR Follow Up Denials Specialist
  • Actively participates in team development, achieving dashboards, and in accomplishing department goals and objectives
  • Responsible for all aspects of follow up and collections on accounts. This includes making outbound calls to payers and accessing payer websites.
  • Collect payments for outstanding claims and ensure payments received are reconciled correctly.
  • Confirm the claim expected reimbursement information to ensure claims are paid correctly. Follows department’s process for follow up on underpayments/overpayments.
  • Research and prepare responses for payor requests for additional information or documentation.
  • Submits corrected claim rebill requests to the PFS Billing team when necessary to send to the insurance payer with correct information and ensures payment is received and claims are paid per contract
  • Research denials and works with other departments such as Coding, Billing, CDM, UM, ect. to resolve denial.
  • Submits the insurance reconsideration/appeals with supporting documentation in a timely manner and follow up with insurance to ensure receipt and processing. Follows insurance payer claims and appeals timely filing guidelines.
  • Communicate clearly and professionally, in both written and verbal manners with internal personnel, payors, providers, patients, and other authorized representatives in regards to outstanding balances.
  • Responsible for adequately working correspondence timely and efficiently (including EOBs, RA’s, denial letters).
  • Maintain knowledge of current government and carrier regulations, policies, manuals relevant to the industry.
  • Identify and report trends in carrier payments and denials, which includes documentation of actions taken to resolve issues. Follows internal escalation process when necessary.
  • Identify complex and aged claims issues and follows internal escalation process appropriately.
  • Maintain patient confidentiality and privacy; adheres to HIPAA standards.
  • Organizes job functions and work assignments to be able to effectively complete assignments within established time frames.
  • Must meet department Productivity Guidelines. Works with all areas of the department to assure maximum productivity. Utilizes the PFS Productivity tracker.
  • Demonstrates knowledge of all equipment and systems/technology necessary to complete duties and responsibilities.
  • Other duties, responsibilities, and activities may change or be assigned at any time with or without notice.

Essential:

• Four years general Patient Accounting experience including understanding of Managed Care contracts and claims analysis. Understanding of Medicaid, Medicaid Manage Care, Medicare, Medicare Advantage plans, Commercial, Liability, and Workers' Compensation payers and their guidelines. Knowledge of healthcare rules and regulations.
• An overall understanding of the appeals processes through completion.
• Ability to read/interpret EOB’s
• Working knowledge of Word, Excel or other Microsoft applications. Good analytical skills for problem solving, typing of 40 WPM and data entry.
• Knowledge of Accounting Principles; analytical mathematical skills, professional customer service communication skills.
• Demonstrates accuracy and thoroughness; Meets productivity standards; Completes work in timely manner.
• Consistently shows ability to recognize and deal with priorities. Adapts to changes in the work environment; Able to deal with frequent change, delays, or unexpected events.
• Knowledge of HIPAA guidelines.
• Demonstrates good judgment and reasoning when investigating and solving problems. Good critical thinking skills.
• Ability to prioritize and manage time effectively.

• Ability to prioritize and manage time effectively.

Essential:

• High School or Equivalent

• Associate Degree

• Business or Healthcare Administration