Clinical Denials Management And Audit

BrightSpring Health Services

Clinical Denials Management and Audit monitors, responds to, and performs the clinical denial and appeal processes across Home Health branches for all payor types striving to improve clinical documentation and minimize lost revenue. They conduct analysis on denials and appeals and identify trends that present process improvement and revenue protection opportunities. Monitor state and federal regulatory agencies to maintain up-to-date knowledge of changing rules and regulations relating to payer requirements and documentation. This position supports the development of standard operating procedures and plans, training, and provides subject matter expertise around clinical documentation and denials management. They will also support detailed level reporting and analytics, clinical appeals, root cause analysis, and address identified trends in reasons for denials; work in partnership with Home Health operations and customers to drive improvement in the quality of services delivered to patients.

Responsible for responding to, managing, and monitoring payer Additional Documentation Requests (ADR) and communications - works with branch staff to gather required information and submit timely responses to ADR requests
• Monitors denials, collaborates with branch and billing staff to determine appropriate response, manages appeals process up to and including the ALJ hearing level
• Receives, monitors, and responds to Government payer Recovery Audit Program (RAC, ZPIC, etc) requests
• Audits patients records for quality and compliance per applicable home health regulations for submission for pre-claim review process of Review Choice Demonstration
• Audits patients records for quality and compliance per applicable home health requirements or for other projects per agency need including but not limited to improvement plans as part of targeted probe and educate surveys, performance improvement programs, and patient safety surveys
• Formulates and submits letters of appeal. Creates an effective appeal utilizing relevant and effective clinical documentation from the medical record; supported by current industry clinical guidelines, evidence-based medicine, local and national medical management standards, and protocols
• Performs ad hoc audits and reporting per request
• Analyzes information gathered by audits and reports and makes recommendations for changes to or development of policy/process and education
• Tracks/trends audit result reporting results and shares with all interested stakeholders (e.g., compliance, legal, clinical support, local operations, and clinical staff)
• Acts as a resource and has expert knowledge of Medicare, Medicaid, and other applicable regulatory requirements
• Provides consultation and education for clinical staff as needed to ensure accurate, timely, compliant documentation that drives accurate billing
• Other duties as assigned

• Requires a degree in Nursing
• Current license/registration by state of hire as a nurse
• Two years of experience in health care utilization review or home care
• Expert written and verbal communication skills and the ability to present to groups of all sizes Strong interpersonal skills
• A thorough knowledge of federal regulations and Medicare requirements is required along with analytical skills to interpret and apply regulatory requirements
• Extensive knowledge of Home Health or Hospice operations, compliance requirements
• Extensive experience in working with Payer requirements, ADR requests, Denials, Appeals, RAC/ZPIC responses
• Ability to prioritize tasks and manage multiple projects
• Strong analytical and problem-solving skills with attention to details
• Ability to utilize a personal computer and other office equipment
• Proficient use of Electronic Medical Record software
• Proficient use of Microsoft Office Suite-Excel, Word, and PowerPoint
• Solid ability to learn new technologies and possess the technical aptitude required to understand flow for data through systems as well as system interaction