Denials Management Specialist
Houston Methodist, Los Angeles, California, United States, 90079
Overview
Come lead with us at Corporate. At Houston Methodist, the Denials Management Specialist (DMS) is responsible for reviewing, coordinating, and monitoring the clinical denial management and appeals process in a collaborative environment with Central Business Office (CBO) management and clinical partners at the various Houston Methodist facilities. This position combines clinical, business, and regulatory knowledge to reduce financial risk and exposure caused by concurrent and retrospective denial of payments for services provided. The DMS reviews denials for level of care, medical necessity, DRG recoupments/downgrades, denials for no authorization, and denials related to an audit review. The DMS collaborates with physicians, case managers, revenue cycle personnel, and payors to appeal technical and clinical denials, and works with management to develop meaningful appeal strategies, staff reference materials, letter templates, education on regulatory standards related to denials, and training. The DMS facilitates accurate reimbursement through appeal writing and provides feedback on process and workflow opportunities as an integral member of the Denials Management team across Houston Methodist facilities.
Responsibilities
Lead denials management by reviewing, coordinating, and monitoring the clinical denial management and appeals process in collaboration with CBO and clinical partners.
Collaborate with physicians, case managers, revenue cycle personnel, and payors to successfully appeal technical and clinical denials.
Develop meaningful appeal strategies, reference materials for staff, letter templates, and education regarding regulatory standards related to denials; train staff and act as a clinical subject matter expert for clinical and technical appeals.
Facilitate accurate reimbursement through appeal writing and provide feedback for process and workflow opportunities to operational and clinical owners as a member of the system Denials Management team.
Essential Functions
People Essential Functions : Train staff in denials and appeals, act as an educational liaison to clinical, revenue cycle, central business office and facility operations staff on payor denials, denial reasons and trends, medical policies, and local/national coverage determinations; contribute to employee satisfaction/engagement.
Mitigate avoidable denials by communicating with physicians, case management, clinical areas, department staff, CBO partners, and vendors to convey payor requirements and reasons for denials; resolve claim delays or denials with clear communication; provide proactive feedback to improve efficiency and reduce denials and write-offs.
Participate in payor meetings and with government reviewers; identify root causes and applicable policies to develop successful appeal strategies.
Service Essential Functions : Provide clinical support for data gathering and review; resolve inpatient and outpatient denials; participate in regular meetings to share denial trends and audit review information; provide feedback to related departments on denials.
Monitor CMS and other regulatory sources for updates related to authorization requirements and denial management; educate appeal staff and management on updates.
Develop tools, templates, and resources to support appeal staff; review letters for appropriateness and clinical accuracy; advise on payor issues to avoid reimbursement at risk.
Quality/Safety Essential Functions : Analyze data from multiple sources to determine denial causes and implement prevention strategies; integrate payor policies, documentation, and regulatory requirements into concise appeal letters; coordinate with IT and Billing to ensure data accuracy and compliance; maintain accurate denial statistics and provide timely reports to management.
Review medical records and remittances for denials; assist in corrective action plans within the denial work group.
Finance Essential Functions
Partner with leadership to reduce denials and identify root causes such as medical necessity, contractual issues, and level of care discrepancies; determine feasibility and strategy for appeals.
Ensure denial trending data and metrics are reported accurately, including CPT/HCPCS, DRG recoupments, and appeal results; monitor payment recovery and trends to implement corrective measures.
Negotiate with payors for adjustments where appropriate, and analyze denials to identify process improvements; work with stakeholders to mitigate avoidable denials.
Growth/Innovation Essential Functions
Collaborate with third-party appeal vendors to identify denial and recovery trends and improve processes.
Identify learning needs, pursue continuing education, and maintain an individual development plan (IDP) with ongoing management discussions.
Qualifications Education
Graduate of an education program approved by the credentialing body for the required credential(s) indicated below in the Certifications, Licenses and Registrations section.
Bachelor of Science preferred
Experience
Seven years of clinical nursing/patient care experience with at least five years in utilization review with clinical decision tools (e.g., InterQual, Milliman) or equivalent revenue cycle clinical role; includes experience initiating and facilitating physician peer-to-peer review, medical/clinical denials and appeals.
Experience with the prior authorization process for all providers, ordering and rendering.
Licenses and Certifications
Required : LVN – Licensed Vocational Nurse; State Licensure – Texas Department of Licensing and Regulation; PSV license in Texas.
Preferred : CPHM, CCM, ACM or equivalent.
Houston Methodist is an Equal Opportunity Employer.
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Come lead with us at Corporate. At Houston Methodist, the Denials Management Specialist (DMS) is responsible for reviewing, coordinating, and monitoring the clinical denial management and appeals process in a collaborative environment with Central Business Office (CBO) management and clinical partners at the various Houston Methodist facilities. This position combines clinical, business, and regulatory knowledge to reduce financial risk and exposure caused by concurrent and retrospective denial of payments for services provided. The DMS reviews denials for level of care, medical necessity, DRG recoupments/downgrades, denials for no authorization, and denials related to an audit review. The DMS collaborates with physicians, case managers, revenue cycle personnel, and payors to appeal technical and clinical denials, and works with management to develop meaningful appeal strategies, staff reference materials, letter templates, education on regulatory standards related to denials, and training. The DMS facilitates accurate reimbursement through appeal writing and provides feedback on process and workflow opportunities as an integral member of the Denials Management team across Houston Methodist facilities.
Responsibilities
Lead denials management by reviewing, coordinating, and monitoring the clinical denial management and appeals process in collaboration with CBO and clinical partners.
Collaborate with physicians, case managers, revenue cycle personnel, and payors to successfully appeal technical and clinical denials.
Develop meaningful appeal strategies, reference materials for staff, letter templates, and education regarding regulatory standards related to denials; train staff and act as a clinical subject matter expert for clinical and technical appeals.
Facilitate accurate reimbursement through appeal writing and provide feedback for process and workflow opportunities to operational and clinical owners as a member of the system Denials Management team.
Essential Functions
People Essential Functions : Train staff in denials and appeals, act as an educational liaison to clinical, revenue cycle, central business office and facility operations staff on payor denials, denial reasons and trends, medical policies, and local/national coverage determinations; contribute to employee satisfaction/engagement.
Mitigate avoidable denials by communicating with physicians, case management, clinical areas, department staff, CBO partners, and vendors to convey payor requirements and reasons for denials; resolve claim delays or denials with clear communication; provide proactive feedback to improve efficiency and reduce denials and write-offs.
Participate in payor meetings and with government reviewers; identify root causes and applicable policies to develop successful appeal strategies.
Service Essential Functions : Provide clinical support for data gathering and review; resolve inpatient and outpatient denials; participate in regular meetings to share denial trends and audit review information; provide feedback to related departments on denials.
Monitor CMS and other regulatory sources for updates related to authorization requirements and denial management; educate appeal staff and management on updates.
Develop tools, templates, and resources to support appeal staff; review letters for appropriateness and clinical accuracy; advise on payor issues to avoid reimbursement at risk.
Quality/Safety Essential Functions : Analyze data from multiple sources to determine denial causes and implement prevention strategies; integrate payor policies, documentation, and regulatory requirements into concise appeal letters; coordinate with IT and Billing to ensure data accuracy and compliance; maintain accurate denial statistics and provide timely reports to management.
Review medical records and remittances for denials; assist in corrective action plans within the denial work group.
Finance Essential Functions
Partner with leadership to reduce denials and identify root causes such as medical necessity, contractual issues, and level of care discrepancies; determine feasibility and strategy for appeals.
Ensure denial trending data and metrics are reported accurately, including CPT/HCPCS, DRG recoupments, and appeal results; monitor payment recovery and trends to implement corrective measures.
Negotiate with payors for adjustments where appropriate, and analyze denials to identify process improvements; work with stakeholders to mitigate avoidable denials.
Growth/Innovation Essential Functions
Collaborate with third-party appeal vendors to identify denial and recovery trends and improve processes.
Identify learning needs, pursue continuing education, and maintain an individual development plan (IDP) with ongoing management discussions.
Qualifications Education
Graduate of an education program approved by the credentialing body for the required credential(s) indicated below in the Certifications, Licenses and Registrations section.
Bachelor of Science preferred
Experience
Seven years of clinical nursing/patient care experience with at least five years in utilization review with clinical decision tools (e.g., InterQual, Milliman) or equivalent revenue cycle clinical role; includes experience initiating and facilitating physician peer-to-peer review, medical/clinical denials and appeals.
Experience with the prior authorization process for all providers, ordering and rendering.
Licenses and Certifications
Required : LVN – Licensed Vocational Nurse; State Licensure – Texas Department of Licensing and Regulation; PSV license in Texas.
Preferred : CPHM, CCM, ACM or equivalent.
Houston Methodist is an Equal Opportunity Employer.
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