Appeal Resolution Specialist jobs in Allentown, PA

Responsibilities

Under the general direction of the Manager of Health Information Management, the Audit and Appeals Coordinator coordinates Recovery Audit Contracting activities to ensure that deadlines are adhered to.  The Audit and Appeal Coordinator is responsible for hospital compliance with all federal, state, and regulatory agencies to manage payer audits and appeals. Assumes the role of system administrator for the Audit and Appeals software product.

These duties will require the understanding of many complex and varying guidelines, systems, regulations and tools. The Audit and Appeals Coordinator will use critical thinking skills to manage an ever-evolving process that includes financial, clinical and legal components. The Audit and Appeals Coordinator will proactively work with GVH staff and physicians to put processes in place and to correct identified deficiencies that are impacted by retrospective denials.

Essential Functions:

• Central contact for sending and receiving correspondence related to Recovery Audit Contractor (RAC), and other payer post discharge denials.
• Coordinates deadlines with hospital staffing including but not limited to Health Information Management, Case Management, and other hospital departments and outside vendors.
• Assumes responsibility for meeting Audit and Appeals deadlines for the health system.
• Assumes responsibility as system administrator of the denials tracking tool including database tables to support the RAC and other post discharge denials program.
• Responsible for ensuring required data is entered into denials tracking tool to produce accurate metrics.
• Provides HIM Leadership with metrics and reports from the Audit and Appeals software system to track appeals activity.
• Performs scheduled reconciliations of the tracking tool to ensure no requests are in jeopardy of not meeting a deadline.
• Notifies HIM Director when changes or problems to the process are identified.
• Maintains a fast paced process of requests and acknowledgements for data and correspondence.
• Coordinates with management to identify and correct weaknesses with billing and financial reimbursement.
• Maintain current third party appeal information in the database in order to provide accurate reporting at various hospital committees. Provides updates until closed or overturned.
• Maintain in the file all correspondences and receipt acknowledgements to ensure receipt by payers.
• Continues to educate oneself and impacted hospital areas and staff on Audit and Appeal industry and program regulations. Stays current on trends related to Medical Necessity, DRG and automated denials by the RAC and other payers.
• Executes Joint Commission audits as requested by management.
• Performs core measure abstraction monthly or as deemed necessary for the organization
• Manages PHC4 data delivery and review to meet regulatory deadlines.

Qualifications

Education and Experience:Bachelor's Degree and over 1 year to 3 years Healthcare Audit and Appeals experience required Licenses and Certifications:RHIA or RHIT certification, Upon hire, preferred

Licensed Practical Nurse/ Registered Nurse in PA – Licensed, Upon hire, preferred

Benefits:• Medical, Free Dental, Vision Insurance for full time and part time• 403B• Pension Plan• On-site discounted Child Care Center• Tuition Reimbursement up to $5250 per year• Free Life Insurance• Free Parking• Paid Time Off• Sick Time• Flexible Spending Accounts• Employee Referral Bonus