Outpatient Clinical Appeal Lead - Remote

Overview

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values-integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.

EEO/AA/Disability/Veteran

Qualifications

Responsibilities:

• 1. Oversight of Governmental appeal function, ensuring timely submission and communication of appeal responses between departments through the ALJ level.
• 2. Ensures released medical record information is complete, timely and in accordance with health system policies and procedures and in compliance with federal and state regulations. Assists in troubleshooting the identification of required documentation from ancillary medical record systems.
• 3. Using certified coding experience, conduct root cause analysis on denied cases, and communicate themes to relevant departments for general knowledge and prevention. As needed, navigate complex governmental regulations for greater insight.
• 4. Drawing on coding and clinical experience, develop thorough compelling appeal letters as needed.
• 5. Collaborate, when necessary, with Clinical Appeal teams, Coding teams, Utilization Review, Clinical Revenue Management, Care Management, and Clinical Departments meet mandated deadlines and manage governmental appeal activity.
• 6. Support commercial audits and appeals in this same manner, as necessary.
• 7. Maintains competency in current EMR System and proficiency in audit tracking systems, develop and maintain skills in ad hoc report development, coordinate departmental reporting of audits and appeals for the facility delivery networks.
• 8. Regularly updates reporting narrative for high level reporting and presentation, develops SBAR communications/memos as needed.
• 9. Consults with Legal Office, Compliance, and Payer Strategy as needed to ensure YNHHS is responding appropriately and per contracted terms.
• 10. Remains current with federal, state and health system regulations /policies/procedures impacting release of information and appeal processes.
• 11. Attends Connecticut Hospital Association (CHA) educational sessions pertaining to compliance and governmental audit activity. Attends CMS webinars pertaining to governmental audits and related programs. Communicates any relevant information to teams and leadership.
• 12. Analyzes RAC findings and other governmental payer audit activity for trends. Regularly communicates updates and analysis to appropriate stakeholders using reports and other tracking.
• 13. Identifies IT related issues and/or improvement opportunities and collaborates with Information Systems & Technology technical support staff and vendors in troubleshooting issues, obtaining, and implementing upgrades as needed.
  
  

Education

Additional Information

Bachelor's degree required. Masters degree related to health/governmental policy, regulatory science, law, etc. is preferred. Certification related to HIM activities is required (i.e., CCS, RHIT, etc.).

Experience

Three to Five year's experience in Health Information Management, ICD-10 Coding, Health IT or related health care or hospital-based operations activities, including experience with audits and appeals. Ability to navigate medical records and other clinical documentation within Epic is essential. Basic understanding of clinical care or concepts is helpful.

Licensure

HIM related certification is required, Certified Coding Specialist (CCS) credential from Ahima is preferred.

Special Skills

Demonstrated excellent oral and written communication skills. Knowledge of medical terminology and state and federal regulations regarding release of medical information. Excellent organizational skills. Strong computer skills. Ability to train new staff, identify and implement workflow improvement activities and develop and maintain organized reporting systems/structure.

Accountability

Accountable for timely and accurate dissemination of patient medical information and appeals to governmental and non -governmental payers and regulatory entities in accordance with state and federal regulations (i.e., HIPAA), payer contract, and YNHHS Administrative policy. Accountable for data integrity related to area functions.

Inherent In The Responsibilities Of This Position)

In personal and job-related decisions and actions, consistently demonstrates the values of integrity (doing the right

thing), patient-centered (putting patients and families first), respect (valuing all people and embracing all differences),

accountability (being responsible and taking action), and compassion (being empathetic).

Complexity

Reviews volumes of medical record requests and appeal opportunities to assist in the distribution of workload to team to ensure efficient operations. Must deal effectively with internal and external customers. Inherent responsibility to promote and maintain good customer relations and to continually improve service. Determines, according to established governmental regulations and hospital guidelines, the availability and extent of medical information to be released . Exercises independent judgment in the release of requested information. Recognizes equipment, systems and procedural problems and takes appropriate action as needed. Represents department at conferences, committee meetings, and other venues pertaining to governmental audits and appeals.

YNHHS Requisition ID

164826

Position Overview

Responsible for the general coordination of Governmental appeals, as well as the timely and accurate fulfillment of records requests for government. Additionally responsible for the organization of data and reporting of audit volumes, outcomes and appeals related to Governmental Audits. The incumbent maintains positive and productive relationships with compliance, third party payers.