Denials Prevention

Description

Summary:

Provides high quality administrative support to Clinical Denial Prevention & Appeals Specialist RNs, Physician Advisors (PAs) and other stakeholders in ensuring all necessary correspondence and submission of documentation required by third party payers is accurate and provided in a timely fashion. This role is instrumental in liaising with all above parties to submit provider appeals to insurance companies including Medicare and Medicaid for the Nuvance Health network. The role also provides support for all administrative and clerical duties to promote efficient and effective department operation. Performs a full range of computer/clerical duties in compliance with Hospital, Governmental, and Regulatory requirements. Works within a variety of computer programs used within the department. Serves as front line liaison for department.�

Responsibilities:

1. Assist with tracking and compiling data for performance metrics and audit readiness.

2. Support onboarding new staff by organizing orientation schedules and materials.

3. Coordinate administrative duties including develop, maintain, and publish the Denial Prevention team�s weekly and monthly work schedules. Ensure sufficient staff coverage for all shifts, including holidays and weekends if applicable. Track time-off requests, holidays, and ensure fair scheduling rotation. Coordinate coverage plans for PTO, sick leave, or other absences. Provide daily administrative assistance to Denial Prevention leadership and clinical reviewers. Manage incoming calls, emails, and correspondence for the Denial Prevention team. Coordinate meetings, prepare agendas, take minutes, and follow up on action items. Maintain confidential departmental files, records, and documentation. Maintain historical records of schedules for audit and HR compliance purposes. Tracks and monitors department expenditures and reconciles expenses and vouchers

4. Faxes the discharge summaries to third party payers. Reviews and documents insurance approval communications, maintaining organized records in shared folders.

5. Serves as UKG payroll editor/approver. Tracks Timesheets for Denial Prevention department including absences, PTO, FMLA, etc.

6. Maintains credentialing/enrollment for Payor Portals sending letter out to vendors, maintaining and updating compliance with requirements

7. Assists in timely sorting and dissemination of requests for medical information from insurers and other sources to the Denial Prevention RNs, PAs, and other coordinators

8. Responds to inquiries and facilitates communications with the System Business Office related to appeals, denial and clinical reviews

9. Reviews new denials and appeal upheld cases in work queue and incoming fax queue.

10. Reviews denial letters through daily mail and sets up appropriate P2Ps.

11. Identifies retrospective denials, documents appropriately and routes to Denial Prevention RN in a timely manner.

12. Communicates with insurance companies to schedule peer-to-peer reviews and follows up on outcomes. Sends appeals with all supporting documents to third party payer(s) within the payer specific timeframe.

13. Documents and updates the denials status in the denial tracking tool in a timely and accurate manner. Collects and analyzes denial data as requested.

14. Interacts professionally with team members within the department, other departments, and insurance companies.

15. Demonstrates the ability to be flexible and organized during stressful situations.

16. Fulfills all compliance responsibilities related to the position.

17. Maintain and Model Nuvance Health Values.

18. Demonstrates regular, reliable and predictable attendance.

19. Performs other duties as assigned.

Other Information:

Working Conditions:

Manual: significant manual skills/motor coord & finger dexterity

Occupational: Little or no potential for occupational risk

Physical Effort: Sedentary/light effort. May exert up to 10 lbs. force

Physical Environment: Generally pleasant working conditions

Company: Nuvance Health

Org Unit: 2092

Department: Care Coordination

Exempt: No

Salary Range: $21.49 - $41.73 Hourly