Job Description
ECU Health
About ECU Health
ECU Health is a mission-driven, 1,708-bed academic health care system serving more than 1.4 million people in 29 eastern North Carolina counties. The not-for-profit system is comprised of 13,000 team members, nine hospitals and a physician group that encompasses over 1,100 academic and community providers practicing in over 180 primary and specialty clinics located in more than 130 locations.
The flagship ECU Health Medical Center, a Level I Trauma Center, and ECU Health Maynard Children’s Hospital serve as the primary teaching hospitals for the Brody School of Medicine at East Carolina University. ECU Health and the Brody School of Medicine share a combined academic mission to improve the health and well-being of eastern North Carolina through patient care, education and research.
Position Summary
Coordinates the appeals process, data entry, and analysis for governmental and commercial denials across ECU Health. Liaison between internal and external parties to ensure timelines are met with regard to appeal preparation and submission. Monitors progression of appealed cases through final appeal process. Acts as software expert to ensure automation enhances the efficiency of the appeals process.
Responsibilities
1) Coordinates collection of payer medical policies and regulatory guidelines for review by Director of Clinical Denials Management or other key stakeholders as appropriate;
2) Coordinates and maintains an electronic medical policy library by payer which may easily be resourced and referenced for conducting peer-to-peer reviews and consults, case management, discharge planning, and managing and challenging denials;
3) Coordinates collection of medical policy updates from commercial payers and ensures widest dissemination to key stakeholders to ensure awareness and compliance with medical policy updates in an effort to prevent avoidable denials;
4) Performs primary data entry for all denials related to medical necessity into appropriate database to ensure day-today tracking and reporting of appeal deadlines and at risk revenues.
5) Updates databases in order to reflect current status of denied cases throughout appeals process. Advises Director of Clinical Denials Management of areas of concern (i.e. trends in payer mix, DRG denials, revenues lost, revenues recovered, level of final appeal, etc.);
6) Utilizes a variety of software and data resources in order to perform data analysis and reporting. Reviews and reconciles database(s) to identify missing or erroneous information.
7) After review and research, ensures database is updated to reflect correct information. Coordinates the production of reports related to Clinical Denial Management activities;
8) Produces monthly assessments that are reported through various committees (e.g. Utilization Review Committee, Revenue Cycle Steering Committee, and other committees as appropriate);
9) Collectively works with Director of Clinical Denials Management to proactively establish and maintain relationships with commercial payers (contracted and non-contracted) in order to identify process changes that will lead to reduction of "administrative" payer denials (e.g. no prior authorization, clinical information not received, etc.). Works with key stakeholders to both identify and correct identified issues;
10) Coordinates the appeals process for denied cases. Duties include, but are not limited to: collection of relevant clinical information to support appeal; Preparation of appeal documents (cover sheets, consent forms, etc.); and Submission of supporting documents to appropriate internal or external party conducting appeal (Office of General Counsel, ECU Health business line leaders, or third party vendors consultants, etc.) to ensure compliance with established timeframes for commercial and governmental appeals.
11) Maintains database of denied cases and updates progress of appeal. Prepares reports to support root cause analysis and other analytical endeavors. Ensures data collection and entry is accurate.
Minimum Requirements
Business or Computer Sciences major.
Progressive experience in utilization management and appeal/denial management.
Database management, data entry, process management, familiarity with appeals management principles; clinical setting preferred.
Associate Degree or higher
Five to seven years related experience
Other Information
General Statement
It is the goal of ECU Health and its entities to employ the most qualified individual who best matches the requirements for the vacant position.
Offers of employment are subject to successful completion of all pre-employment screenings, which may include an occupational health screening, criminal record check, education, reference, and licensure verification.
We value diversity and are proud to be an equal opportunity employer. Decisions of employment are made based on business needs, job requirements and applicant’s qualifications without regard to race, color, religion, gender, national origin, disability status, protected veteran status, genetic information and testing, family and medical leave, sexual orientation, gender identity or expression or any other status protected by law. We prohibit retaliation against individuals who bring forth any complaint, orally or in writing, to the employer, or against any individuals who assist or participate in the investigation of any complaint.
General Statement
It is the goal of ECU Health and its entities to employ the most qualified individual who best matches the requirements for the vacant position.
Offers of employment are subject to successful completion of all pre-employment screenings, which may include an occupational health screening, criminal record check, education, reference, and licensure verification.
We value diversity and are proud to be an equal opportunity employer. Decisions of employment are made based on business needs, job requirements and applicant’s qualifications without regard to race, color, religion, gender, national origin, disability status, protected veteran status, genetic information and testing, family and medical leave, sexual orientation, gender identity or expression or any other status protected by law. We prohibit retaliation against individuals who bring forth any complaint, orally or in writing, to the employer, or against any individuals who assist or participate in the investigation of any complaint.
Contact Information
For additional information, please contact:
Angie Nichols, Talent Acquisition Consultant
ECU Health Talent Acquisition
Email: [email protected]
