Current jobs related to Appeals Specialist - Somerville - Massachusetts General Hospital

Appeals SpecialistMass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.We are repurposing the BWH PN0011649 to the Appeals Specialist position.Under the general guidance of the Patient Access Services Denial Manager, the Admitting Department Appeals Specialist is responsible for assisting with insurance denials and is expected to adhere to programs, policies, and procedures to maximize reimbursement by minimizing denials. Under the supervision of the Patient Access Manager, the Appeals Specialist also monitors Huron and EPIC reports and work queues to ensure timely response to denied cases, prepares and submits appeals, and provides follow-up on cases until resolution has been achieved. Reviews appealed cases to assist in the determination of departmental write-offs, as appropriate. Cultivates, maintains, and enhances relationships with third-party payors. The analyst performs all these functions in a manner that complies with standards established by the Hospital Administration, Medical Staff, and outside regulatory and accreditation agencies. Works toward goals and objectives for departmental denial management.Has a sound understanding of the payer rules related to the denials and appeals.Communicates directly with payers, Payor Operations, BWF and BWH Case Management, Admitting, Revenue Operations, Central Billing Office, and other appropriate hospital and physician staff to coordinate appeal activity if deemed necessary.Cultivates, maintains, and enhances relationships with third-party payors.Provides case follow-up on denials until resolution has been achieved.Formulates and submits timely, well-prepared appeals with supporting clinical information and required data and provides this information to third-party administrators (payers).Assists in the determination of write-offs and analysis provided to the Executive Director for review and approval.Reviews Huron and EPIC reporting and documentation to determine the root causes for denials and works to implement action plans to prevent future denials.Maintains clear channels of communication for effective problem-solving, as related to denials, and troubleshoots routine and non-routine problems and takes appropriate actions to address issues.Contributes to teamwork within and between departments. Attends and participates in related meetings as needed.Positively provides constructive ideas and suggestions.Works collaboratively with co-workers and management to effectively resolve issues that impact departmental or hospital operations in order to increase reimbursement and minimize denials.Performs various administrative functions, including, but not limited to, supporting management of payer contractions and contract operations around denials including compiling and summarizing denial data and trends in Excel and Word to support meetings and events.Assists in the design and implementation of programs to monitor denial and reduce denials.Works efficiently to meet appeal response deadlines (i.e. fax, telephone, online, etc.)Assists in the implementation of Quality Assurance programs targeting as goals not only accuracy and efficiency but also high levels of patient and physician satisfaction.Assists in the development of functional specifications/requirements for computer systems, new computer programs, and enhancements to existing systems.In conjunction with Information Systems, Care Coordination, and the Finance Department, assists in the design, creation, and verification of EPIC and Huron Reporting and dashboards.Assures accuracy and completeness of data collected by Patient Access Services and submitted to third-party payors.Works with Information Systems regarding system maintenance, enhancements, and/or upgrades.Develops manual procedures to handle computer downtime and crash recovery.Creates an environment that encourages productivity, loyalty, job satisfaction, and a positive attitude.Adheres to the hospital's personnel policies and procedures.Assists management with analysis related to operating and capital budgets.Generates and implements new ideas for reducing costs.Actively participates in designated special projects as needed.Maintains ongoing knowledge of legislative and regulatory changes that impact hospital access to care and quality of care.QualificationsHigh School diploma/GED required.Bachelor's degree in business, accounting, or healthcare-related field preferred.Minimum of 2-4 years in a health care setting with administrative and financial work experience.Denials or appeals experience required.Requires effective, results-oriented skills.Requires interpersonal skills to interact effectively with all levels of staff, management, and leadership.Must be able to collaborate in an effective interdisciplinary team approach.Requires superior problem-solving skills and the ability to work with multiple demands and priorities.Requires independent judgment to deviate from standard policies, procedures, and schedules when necessary.Requires excellent communication skills both oral and written. - Requires sound analytical skills.Requires knowledge of computers and management information systems and the ability to provide specifications for program development, system enhancements, and reports.Requires strong computer skills and understanding to efficiently data mine denial data and presentation skills (e.g. Excel, Word), Powerpoint).Due to the volume of denials, and complexity in analysis, the pace of work is hectic and challenging, the workload could necessitate working off hours.Must be able to adapt to changes in the workspace.Ability to work well in a demanding and changing environmentAssist with training of new employees when necessary.The key to the institution's financial viability lies in the integrity of the data collected. The work performed by the Admitting Appeals Specialist is a cornerstone of the institution's reimbursement. This position plays a crucial role in preventing denials through root cause analysis and writing appeals as well as assisting with retro-authorizations and analysis.Additional Job Details (if applicable)Remote Type: RemoteWork Location: 399 Revolution DriveScheduled Weekly Hours: 40Employee Type: RegularWork Shift: Day (United States of America)Pay Range: $62,400.00 - $90,750.40/AnnualGrade: 6At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.0100 Mass General Brigham Incorporated is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran's Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.Mass General Brigham Competency FrameworkAt Mass General Brigham, our competency framework defines what effective leadership "looks like" by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.