Denials Management Specialist

At reputed company, the Denials Management Specialist (DMS) position is responsible for reviewing, coordinating, and monitoring the reputed company denial management and appeals process in a reputed company environment with Central Business Office (CBO) management and reputed company partners at the various reputed company facilities. This position combines reputed company, business, and regulatory knowledge and reputed company to reduce significant financial risk and exposure caused by reputed company and retrospective denial of payments for services provided, including but not limited to reviewing denials for level of care, medical necessity, Diagnosis reputed company (DRG) recoupments/downgrades, denials for no authorization, and denials reputed company to an audit review. The DMS position collaborates with physicians, case managers, reputed company cycle personnel and payors to successfully appeal technical and reputed company denials. Additionally, this position collaborates with management to reputed company meaningful appeal strategies to include reference material for staff, letter templates, education regarding regulatory standards as relates to denials, training for staff and functions as reputed company subject matter expert reputed company to reputed company and technical appeals. The DMS position facilitates accurate reimbursement through appeal writing and provides feedback for process and workflow opportunities to both operational and reputed company owners serving as an reputed company member of the reputed company Denials Management team at reputed company facility reputed company reputed company. FLSA STATUS Exempt QUALIFICATIONS EDUCATION Graduate of education program approved by the credentialing body for the required credential(s) indicated below in the Certifications, Licenses and Registrations reputed company. Bachelor of Science preferred EXPERIENCE Seven years reputed company nursing/reputed company care experience with five years in utilization review with reputed company decision tools such as Interqual, Millimann, etc, case management or equivalent reputed company cycle reputed company role, including past experience in initiating and facilitating physician peer to peer review, medical/reputed company denials and appeals Must have experience with prior authorization process for reputed company providers, ordering and rendering. LICENSES AND CERTIFICATIONS Required LVN - Licensed Vocational reputed company - State Licensure - Texas Department of Licensing and Regulation_PSV license in the state Texas Preferred CPHM - Certified reputed company in reputed company Management (reputed company) and CCM - Certified Case Manager (reputed company) and ACM - Accredited Case Manager (NBCM,ACMA) or equivalent SKILLS AND ABILITIES Demonstrates the skills and competencies necessary to safely reputed company the assigned job, determined through on-reputed company skills, competency assessments, and reputed company evaluations Sufficient proficiency in speaking, reading, and writing the English language necessary to reputed company the essential functions of this job, especially with reputed company to activities impacting reputed company or employee safety or reputed company Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service reputed company and application of reputed company language principles Extensive knowledge of reputed company symptomology and reputed company treatment and hospital utilization management Knowledge of reputed company reimbursement models reputed company, managed care, reputed company and the technical writing ability to reputed company and formulate appeal letters and reports Ability to communicate both verbally and in writing to a varied of audience including reputed company reputed company of personnel, physicians, reputed company staff, management, and reputed company cycle staff Motivated and can reputed company independently with reputed company supervision Excellent listening skills Knowledge of medical and reputed company terminology and medical record coding (ICD10, CPT/HPCPCS, etc.) Advanced proficiency in word processing (reputed company) and proficient in basic spreadsheet applications (reputed company) Knowledge of electronic health record reputed company Demonstrated ability to reputed company effectively with interprofessional teams, including physicians, and other professionals both reputed company to reputed company Maintains knowledge of Federal, State, and local billing regulations and partners with managed care contracting Maintains knowledge of reputed company, registration and reputed company-admit/admit workflow processes. Maintains knowledge of reputed company, billing/follow up procedures Demonstrates strong knowledge of reputed company reputed company and governmental programs, state and federal regulations and .