This is a hybrid position-location 701. S Fry Katy, TX 77450

Looking for candidates with the following:

• Appeals with hospital accounts
• Epic experience is a plus
• Government Advantage Payers
• Hospital Revenue Cycle experience

At Houston Methodist, the Accounts Receivable (AR) Appeals Denials Specialist position is responsible for reviewing accounts which have been denied or underpaid by third party payors, resolving the issues resulting in denial/underpayment, and submitting formal appeals with the goal of maximizing reimbursement for the services provided by Houston Methodist. This position is responsible for understanding healthcare contracting terms and requirements in order to address underpayments and denials in accordance with regulatory and contractual obligations. This includes contract content review, application of appropriate contract terms and fee schedule(s), and a thorough understanding of the requirements of the Government and Non-Government payment policies and payer contracts. Additionally, this position identifies accounts with payment review opportunities, appropriately communicating with payors and/or Managed Care regarding contract compliance responsibilities and resolving reimbursement discrepancies. This position must be able to articulate an argument or justification for additional reimbursement to the payor for services provided. This position works both independently and as a part of the Accounts Receivable Team, as well as with other teams within revenue cycle and throughout the health system.

PATIENT AGE GROUP(S) AND POPULATION(S) SERVED
Refer to departmental "Scope of Service" and "Provision of Care" plans, as applicable, for description of primary age groups and populations served by this job for the respective HM entity.

HOUSTON METHODIST EXPERIENCE EXPECTATIONS

• Provide personalized care and service by consistently demonstrating our I CARE values:
  • INTEGRITY: We are honest and ethical in all we say and do.
  • COMPASSION: We embrace the whole person including emotional, ethical, physical, and spiritual needs.
  • ACCOUNTABILITY: We hold ourselves accountable for all our actions.
  • RESPECT: We treat every individual as a person of worth, dignity, and value.
  • EXCELLENCE: We strive to be the best at what we do and a model for others to emulate.

• Practices the Caring and Serving Model

• Delivers personalized service using HM Service Standards

• Provides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET, Managing Up, Key Words)

• Intentionally collaborates with other healthcare professionals involved in patients/customers or employees' experiential journeys to ensure strong communication, ease of access to information, and a seamless experience.

• Involves patients (customers) in shift/handoff reports by enabling their participation in their plan of care as applicable to the given job

• Displays cultural humility, diversity, equity and inclusion principles

• Actively supports the organization's vision, fulfills the mission and abides by the I CARE values

PEOPLE ESSENTIAL FUNCTIONS

• Promotes a positive work environment and contributes to a dynamic team focused work unit that actively helps one another to achieve optimal department and organizational results.

• Strikes a balance between maintaining trustful relationships and ensuring timely payments. Exhibits professionalism and trustworthiness.

SERVICE ESSENTIAL FUNCTIONS

• Reviews accounts, takes appropriate action, and documents per departmental standards. Ensures the reason for denial (clinical, administrative, or technical) is clearly stated on the payment documentation. Handles technical issues and forwards clinical and administrative issues to the appropriate group for review.

• Confers with Billers, as necessary, to obtain additional information/clarification and requests rebills as needed.

• Researches denials and determines if there is a legitimate case for overturning the denial, in accordance with the payor's medical policy or the contract. Drafts and submits appeals using a sound argument for denials that have a reasonable chance of being overturned.

• Informs manager of payor trends or any problems or changes in payor requirements, including any barriers or obstacles.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Provides clear and concise documentation of every action taken on an account in the system collection notes. Provides balance breakdown to document the status of next responsible party (i.e., primary, secondary payor, patient balance, or credit balance).

• Identifies accounts for advanced due diligence steps or legal placement in accordance with department policy and procedure. Effectively manages inventory in accordance with departmental standards.

• Utilizes contracting modeling and notifies manager if incorrect payments/contractuals are being calculated.

• Meets or exceeds stated Performance Indicator Expectations (e.g., productivity, account reviews, agings) as demonstrated on weekly Key Performance Indicator.

FINANCE ESSENTIAL FUNCTIONS

• Follows up on assigned delinquent insurance claims. Ensures maximization of collection dollars from insurance companies in accordance with the respective contract and/or Houston Methodist financial arrangement.

• Analyzes accounts for errors, adjustments and credits, issuing corrected entries when necessary. Updates account information accordingly. Follows levels of authority for posting adjustments, refunds, and contractual allowances.

• Uses resources effectively and efficiently. Organizes time effectively, minimizing incidental overtime, and sets priorities. Utilizes time between heavy workloads efficiently and helps other team members.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Stays current on various payors and industry trends. Seeks opportunities to expand learning beyond baseline competencies with a focus on continual development.

• Generates and communicates new ideas and suggestions that will improve quality or service. Demonstrates adaptability and flexibility in the face of changing demands.

This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.

EDUCATION

• Bachelor's degree (preferably in business administration, finance, healthcare administration, or related discipline) or additional four years of experience (in addition to the minimum experience requirements listed below) in lieu of degree

WORK EXPERIENCE

• Three years of experience working in contract compliance or revenue cycle environment

LICENSES AND CERTIFICATIONS - REQUIRED

• N/A

KNOWLEDGE, SKILLS, AND ABILITIES

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations

• Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security

• Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles

• Extensive knowledge of claims reimbursement and collection efforts for Managed Care, Medicare, Medicaid, Workers Comp, Commercial plans, etc.; knowledge of how to interpret a managed care contract, Medicare and Medicaid and Workers Compensation

• Extensive knowledge of billing, collections, reimbursement, contractual agreements and the appeals process

• Understanding of revenue cycle fundamentals

• Ability to follow-through and handle multiple tasks simultaneously

• Excellent writing, oral and interpersonal communication skills in order to present case for appeal

• Excellent negotiation skills, as well as an ability to work independently and interdependently with other business office staff

• Good judgment in handling of accounts and ability to apply a professional approach in dealing with patients and insurance companies

• Sharp analytical abilities in order to resolve patient accounts in a timely and correct manner

• Proficient computer skills and ability to learn and navigate multiple software programs

• Ability to remain calm in stressful situations with patience and understanding

• Ability to approach problems with an open mind and contribute to solutions

SUPPLEMENTAL REQUIREMENTS

WORK ATTIRE

• Uniform No
• Scrubs No
• Business professional Yes
• Other (department approved) Yes

ON-CALL*
*Note that employees may be required to be on-call during emergencies (ie. DIsaster, Severe Weather Events, etc) regardless of selection below.

• On Call* No

TRAVEL**
**Travel specifications may vary by department**

• May require travel within the Houston Metropolitan area No
• May require travel outside Houston Metropolitan area No

Houston Methodist (HM) is one of the nation’s leading health systems and academic medical centers.  HM consists of eight hospitals: Houston Methodist Hospital, its flagship academic hospital in the heart of the Texas Medical Center, and seven community hospitals throughout the greater Houston metropolitan area.  HM also includes an academic institute, a comprehensive residency program, a global business division, numerous physician practices and several free-standing emergency rooms and outpatient facilities.  Overall, HM employs over 25,000 employees.   Houston Methodist is supported by a wide variety of business functions that operate at the system level to help enable clinical departments to provide the best patient care and service in a spiritual environment.

In 2019 Houston Methodist and its physicians treat more than 6,333 international patients from more than 76 countries. Houston Methodist Global Health Care Services’ consulting and education divisions also provide advisory services and training and development to health care organizations around the world.