Outpatient Clinical Appeal Lead - Remote

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

Responsibilities:

1. Support the revenue cycle operation of the health system and serve as subject matter expert of outpatient
clinical audit and appeal functions.

2. Oversight of outpatient clinical audit/appeal function, ensuring timely submission and communication of
audit/appeal responses between departments through the highest level of appeal.

3. Assist all team members as needed with complex audit/appeal issues and scenarios for timely submission of
audits/appeals, contributing to the resolution of issues.

4. Assist all team members in identifying additional required medical record documentation ancillary systems to
support the medical necessity of the services in question.

5. Will conduct root cause analysis on denied cases and share themes with relevant areas. As needed ,
navigate complex payer requirements for greater insight.

6. Drawing on coding and clinical experience, support the development of thorough compelling clinical appeal
letters.

7. Collaborate with various revenue and clinical departments throughout the health system to meet required
deadlines and maintain timely oversight of clinical appeal activity.

8. Support leadership in communications with the legal office, compliance, payer strategy to ensure YNHHS is
responding appropriately by contracted or regulatory terms.

9.Will develop and maintain skills in ad hoc report development and coordinate departmental reporting of
appeals for the facility?s delivery networks.

10. Regularly updates reporting narrative for high level reporting and presentation, develops SBAR
communications/memos as needed.

11. Analyzes denial and appeal related activity for trends and outcomes. Regularly communicates updates and
analysis to appropriate stakeholders using reports and other tracking.

12. Attends Connecticut Hospital Association (CHA) educational sessions pertaining to billing, coding, and denial
related activity. Attend payer webinars related to denial and cost recovery programs. Communicates any
relevant information to teams and leadership. Monitor for continuing education opportunities related to clinical
denials and appeals and coordinates attendance for the department.

13. Attend monthly payor meetings for escalation of unresolved appeals.

14. Maintains competency in current EMR System and proficiency in audit tracking systems.

15. Identify IT related issues and/or improvement opportunities and collaborate with relevant teams for
troubleshooting, corrections, or implementation of new technical processes.

EDUCATION:

Bachelor's degree required. Master's degree related to health/governmental policy, regulatory science, law, etc. is preferred. Certification related to HIM activities is required (i.e., CCS, RHIA, CPC, COC, CIC, etc.).

EXPERIENCE:

Three to Five years' experience in Health Information Management, ICD-10 Coding, Health IT or related healthcare 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). 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 teams 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.

The Outpatient Clinical Audit/Appeal Lead will support the Clinical Audit/ Appeals and Denial Prevention Management team with oversight of clinical audit and appeal activity inclusive of all payor types. Responsibilities include the organization of data and reporting of outpatient clinical audit /appeal volumes and outcomes, monitor benchmarks and reviews performance statistics, and identify opportunities for workflow efficiency and effectiveness. The individual must be able to collaborate with all team members, insurance payors, including third party, and various departments throughout the health system relative to the clinical audit/appeal work.