Denials and Refund Management Specialist

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

The Denials and Refund Management Specialist will be focused on refund requests - you will be reading, interpreting, and analyzing commercial contracts. Once you are able to validate whether or not the request is valid, you will submit the appeal to contest the refund. Once the appeal is granted, you will request a refund from the commercial payors due to the claim having been declined instead of accepted. People who have a very extensive background in interpreting and analyzing commercial contracts will do well in this position.

This position is full-time, Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 7:00am - 3:30pm PST. It may be necessary, given the business need, to work occasional overtime. Employees are required to work 1 day onsite and 4 days from home.

We offer 2 weeks of paid training. The hours during training will be 8:00am - 4:30pm PST, Monday - Friday.

If you are within commutable distance to the office at 5003 Commercial Circle, Concord, CA 94520, you will have the flexibility to work from home and the office in this hybrid role as you take on some tough challenges.

Primary Responsibilities:

• Collect and resolve denied payments from insurance companies by contacting assigned payers
• Execute the denial appeals process, which includes receiving, assessing, documenting, tracking, responding to, and/or resolving appeals with third-party payers in a timely manner
• Research and resolve payer rejected/denied claims and analyze accounts for insurance payment accuracy/completeness and for payer claim processing accuracy per contract. Work with clinical staff as needed to follow-up and appeal denials
• Maintain data on the types of claims denied and root causes of denials, and collaborate with team members to make recommendations for improvement and issue resolution
• Prepare, maintain, assist with, and submit reports as required
• Track and trend recovery efforts by utilizing various departmental tools. Appropriately report on-going problems specific to, health system departments, and/or contracts
• Provide feedback and process improvement ideas to management regarding facility, Patient Access, Case Management, HIM, Billing and/or payer issues identified when reviewing accounts for appeal
• Draft professional appeal letters in accordance with methodology in departmental policy and procedure including using correct grammar and spelling
• Identify contract issues related to denials and communicate those issues to Director of Revenue Integrity
• Provide on-going feedback to clinical staff about denial reasons, appeals and their outcomes, and managed care contractual requirements
• Transmit required documentation to Government and third-party payers for the purpose of resolving payments.
• Ensure all payer contact is fully documented in the appropriate software application
• Ensure claims are crossed over to secondary insurances, reporting any delay in unbilled secondary claims to the unit supervisor
• Consistently meet the current productivity standards in addressing and resolving denied accounts
• Consistently meet the current quality standards in taking appropriate actions to identify and track root causes, successfully appeal denied accounts, and trend issues
• Provide individual contribution to the overall team effort of achieving the department AR goal
• Identify opportunities for system and process improvement and submit to management
• Demonstrate proficient use of systems and execution of processes in all areas of responsibilities
• Demonstrate knowledge of John Muir Health System HIPAA privacy standards and ensure compliance with system PHI privacy practices
• Follow the Health System's general Policy and Procedures, the Department's Policy and Procedures, and the Emergency Preparedness Procedures
• Become cross-trained and fill in for other staff as assigned
• Follow department guidelines for lunch, breaks, requesting time off, and shift assignments
• Operate office equipment and machinery and utilizes ergonomic workstations, equipment, and supplies
• Follow JCAHO and outside regulatory agencies' mandated rules and procedures
• Utilize assigned menus and pathways in the hospital mainframe system. Report software application problems to the appropriate supervisor
• Utilize assigned menus and pathways in foreign software applications. Report software application problems to the appropriate supervisor
• Utilize assigned computer hardware. Report hardware problems to the appropriate supervisor
• Participate in the testing for assigned software applications, including verification of field integrity
• Perform other duties and responsibilities as assigned
• Maintain confidentiality in matters relating to patient/family
• Assure patient privacy and confidentiality as appropriate or required
• Ensure minors have a parent or guardian listed as guarantor as appropriate
• Maintain professional relationships and convey relevant information to other members of the healthcare team within the facility and any applicable referral agencies
• Initiate communication with peers about changes and procedures
• Relay information appropriately over telephone, email, and other communication devices
• Interact with internal customers including HIM, Revenue Integrity, Patient Access, and the SBO in a professional manner to achieve revenue cycle department AR goals and objectives
• Assist with special projects as assigned
• Work closely with other staff, co-workers, peers, and other members of the healthcare team to ensure a positive and effective work environment
• Report to appropriate personnel regarding assignments, projects, etc.
• Initiate problem solving and conflict resolution skills to foster effective work relationships with peers
• Report to work on time and as scheduled
• Attend staff meetings, in-services, and continuing education
• Assist in the development of indicators, thresholds, study methods, and data collection as assigned
• Respond to problems/opportunities to improve care/customer service
• Support involvement in system performance improvement initiatives
• Participate in and maintain competencies required for the position and specific unit/area(s) of assignment