Utilization Revenue Appeal Specialist
The HBAA Team Lead, under supervision by the HBAA Manager, will participate in the oversight of the day-to-day operations of the HBAA department at the University of Michigan Health System. This position will provide guidance to staff members related to identification and prioritization of overall work activities and will provide expert knowledge in support of the resolution of HBAA work issues that arise. This position will also function as the educator and quality improvement coordinator for the HBAA team.
- Compilation and maintenance of payer updates pertinent to Audits & Appeals team
- Development and maintenance of HBAA-specific orientation checklist and training materials/job aids/tip sheets for new and existing staff
- Facilitation and maintenance of cross-training for all HBAA staff
- Review patient medical records and utilize clinical and regulatory knowledge as well as knowledge of payer requirements to determine reasons for denials and what type of appeal is required.
- Utilize payer specific communication protocols and document all contacts, including outcomes to assure appropriate payment of claims for approved services. Document all denied services, appeal dates and maintain records of correspondence throughout the appeal process.
- Collaborate with physicians, PA’s, Compliance department and Health System Legal office to ensure complete and accurate information on all appeal letters.
- Make appeal referrals to both internal and external physician advisors. Utilize knowledge of third party regulations to initiate appropriate interventions.
- Make recommendations for further appeal, referrals to UMHS contracting and/or legal offices.
- Utilize knowledge of CMS regulations, OPPS coding for surgical procedures and the Medicare inpatient only list to ensure accurate reimbursement.
- Coordinate and conduct admission, readmission, concurrent and retrospective medical necessity reviews for Psych admissions. Determine appropriate level of care based upon completed clinical review, utilizing knowledge of disease processes, treatment regimens and anticipated outcomes along with established medical necessity criteria. Initiate appropriate interventions when criteria is not met for admission or continued stay. Meet payer requirements for accurate billing of claims.
- Review readmissions and apply payer guidelines. Combine accounts as necessary prior to release of claims.
- Complete and maintain MiChart, ADT and Billing workqueues. Assure quality of data on claims prior to billing and recovery of revenue on claim rejections.
- Develop educational materials and provide training and development to new and existing Revenue Cycle Audits & Appeals staff. Assess competency at completion of training and provide further mentoring as needed.
- Monitor Medicaid retrospective eligibility cases, complete required forms, track retrospective authorizations or need for appeal.
- Collaborate with other revenue cycle and patient care departments and the health care teams to improve outcomes. Attend and participate in departmental and interdisciplinary meetings and committees. Incorporate learning into operational activities as appropriate.
- Assist in the overall achievement of the objectives and financial goals of the University of Michigan Hospital and Health Systems.
- An Associate degree in Health Information Technology or Associate degree RN, with at least 3-5 years of recent experience in, Audit Management, Revenue Cycle Appeals Management or Case Management is required.
- RHIT Certification
- Current/active certification/licensing through professional association
- Strong communication skills, with emphasis on excellent writing skills
- Required computer skills: Microsoft Office applications (i.e., Word, Excel), EHR. Ability to use and master multiple computer systems and applications.
- Ability to maintain confidentiality according to HIPPA regulations.
- Detail-oriented, organized, strong problem-solving skills, strong investigative skills, critical thinking skills and ability to be self-directed and work independently
- Experience as an educator or experience with development of orientation/training materials for staff
- Team lead experience
- Quality improvement experience
- Experience with a case management/utilization management software program and EPIC (MiChart)
- Knowledge of University policies and procedures
- Payer appeals experience in a healthcare setting
- Knowledge of third party payer regulations and reimbursement methodologies and payer audit and appeal requirements
- Strong interpersonal and written communication skills, problem solving, decision making, and negotiation skills are necessary. Must have demonstrated the ability to work well with physicians and other health care providers
- Able to write clearly and informatively; edit work for spelling and grammar; able to interpret written information
Michigan Medicine conducts background screening and pre-employment drug testing on job candidates upon acceptance of a contingent job offer and may use a third party administrator to conduct background screenings. Background screenings are performed in compliance with the Fair Credit Report Act.
Michigan Medicine improves the health of patients, populations and communities through excellence in education, patient care, community service, research and technology development, and through leadership activities in Michigan, nationally and internationally. Our mission is guided by our Strategic Principles and has three critical components; patient care, education and research that together enhance our contribution to society.
Job openings are posted for a minimum of seven calendar days. This job may be removed from posting boards and filled anytime after the minimum posting period has ended.
U-M EEO/AA Statement
The University of Michigan is an equal opportunity/affirmative action employer.