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Job Description
Job Summary
Manages, monitors, supports, and reports on the consistency and adequacy of Spectrum Health's responses to requests for post payment audits, serving as the central point person for all Spectrum Health post payment audit activity. Acts as the central contact for sending and receiving correspondence related to audits; coordinates the clinical responses provided by Spectrum Health on adverse audit determinations; consults with legal counsel; evaluates data associated with audit activities; tracks and measures the effectiveness of Spectrum Health's responses; and reports to management on a regular basis. Makes recommendations for process improvements, as part of the denials and post payment audit team.
Essential Functions
- Maintains expert knowledge of post payment audit and denial issues. Stays current on trends related to medical necessity, diagnosis-related group (DRG), and automated denials.
- Utilizes department specific as well as external software applications determined by management to maximize efficiency and effectiveness of department workload. Develops and maintains databases.
- Maintains a fast-paced process of requests and acknowledgements for data and correspondence. Identifies and corrects weaknesses in the process and alerts management in the event of potential technical denials due to not meeting date sensitive deadlines.
- Maintains an understanding of many complex and varying guides, systems, regulations and tools. Utilizes critical thinking skills to manage an ever-evolving process that includes financial, clinical and medical/legal components.
- Develops and implements effective support systems to ensure accurate documentation. Ensures availability of all reports and records for area of responsibility. Prepares reports of post payment audit findings and recommendations for management. Maintains electronic records of audits, issues and investigations in accordance with departmental practices. Assists in the compilation and production of reports to the Spectrum Health Denials Steering Committee. Makes sure account activity is tracked, updating systems/spreadsheets on a regular basis to ensure proper tracking and follow-up.
- Works with director, manager and leadership to develop and revise policies and procedures related to post payment audits.
- Presents post payment audit findings to Denials Steering Committee and Post Payment Audit Workgroup as needed.
Qualifications
- Required Bachelor's Degree or equivalent education and experience
- 3 years of relevant experience or more working in patient financial services, revenue cycle, or similar field Required
- Exposure to clinical, nursing, ancillary, and finance/business office environments Required
- Lens, Facets and Excel experience preferred
- Prior claims experience preferred
- Medical Terminology experience preferred
Primary Location
SITE - Priority Health - 1231 E Beltline - Grand Rapids
Department Name
PH - Inpatient Utilization Management
Employment Type
Full time
Shift
Day (United States of America)
Weekly Scheduled Hours
40
Hours of Work
8 a.m. to 4:30 p.m.
Days Worked
Monday to Friday
Weekend Frequency
N/A
Spectrum Health requires all team members to receive the COVID-19 vaccinations subject to certain exclusions based on the team member’s job category. Spectrum Health is committed to granting reasonable accommodations in accordance with applicable laws.
Accommodation Notice: If you are a qualified individual with a disability, you may request a reasonable accommodation in Spectrum Health's application process. Contact us at 616-486-SHHR (7447).
Spectrum Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, sexual orientation, veteran status, or any other legally protected
category. See more here.