Responsible for the review, appeal strategy, resolution and reporting of payer claim denials to recover reimbursement for EvergreenHealth. Maintains accountability for final appeal determinations and financial outcomes of assigned denials, including validation of triage decisions and direction of appeal activities. Analyzes denial trends, develops appeal strategies, collaborates with clinical and operational departments, and maintains detailed documentation throughout the appeal lifecycle. Communicates with payer representatives, contributes to denial prevention efforts, and adapts to evolving payer policies and system upgrades.
Primary Duties:
1. Reviews and validates recommended next steps for referred claim denials. Maintains final responsibility for appeal strategy and financial outcome.
2. Maintains accurate documentation of denial activity and appeal actions in electronic medical record (EMR) system and supporting tools.
3. Develops appeal strategy and drafts and submits timely appeals supported by documentation, clinical input, and payer criteria.
4. Collaborates with departments including Case Management, Coding, and Health Information Management (HIM) to gather supporting documentation that will strengthen the appeals.
5. Refers complex or escalated denials to senior team members or leadership as appropriate.
6. Reviews and validates denial trends and communicates payer feedback to promote consistency in documentation, appeal strategy, and resolution processes.
7. Monitors payer websites for changes in reimbursement requirements that impact denial management processes.
8. Participates in training focused on denial trends, payer-specific appeal strategies, and continuous learning around EMR tools.
9. Performs other duties as assigned.
License, Certification, Education or Experience:
REQUIRED for the position:
● Associate's degree in related area or equivalent combination of education and experience
● 5 years of experience in denial management, utilization review or prior authorization in a hospital, provider, or healthcare system.
● Experience in healthcare billing and reimbursement
● Experience with EMR system workflows
● Strong knowledge of health care services reimbursement methodologies
● Knowledge of claim forms and remittance advices, including coding and billing practices
● Ability to interpret contract language
● Working knowledge of medical terminology
DESIRED for the position:
● Bachelor's degree
● Previous training experience and knowledge of adult learning
● Experience with Epic EMR
