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Denials & Appeals Management Sr. Manager (Hospital Claims) Plano, TX at NTT Data, Inc

Posted in Other 30+ days ago.

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Type: Full Time
Location: Plano, Texas





Job Description:

At NTT DATA we know that with the right people on board, anything is possible. The quality, integrity, and commitment of our employees have been key factors in our company s growth and market presence. By hiring the best people and helping them grow both professionally and personally, we ensure a bright future for NTT DATA Services and for the people who work here.

Req ID: 16238

NTT DATA SERVICES IS HIRING!

Top 10 Global Services Firm is seeking a Senior Manager with Denials and Appeals Management (Hospital Claims) for our Business Process Outsourcing (BPO) Practice in Plano, TX

THE COMPANY
NTT DATA Corporation is a top 10 global services company and part of the NTT Group, a Fortune 29 telecommunications and services company based in Japan. We operate with 60,000 professionals in 36 countries. Every day around the world we help clients explore new ways to respond to market dynamics with flexibility and speed, reduce costs with less risk, and increase productivity to enable growth.

THE OPPORTUNITY

For more than 30 years, our Business Process Outsourcing team has implemented the processes and technologies for Healthcare clients that bring about real transformation for customers of all sizes. Our end-to-end administrative services help streamline operations, improve productivity and strengthen cash flow to help our customers stay competitive and improve member satisfaction.

JOB DESCRIPTION

Looking for an Expert who has knowledge and skill to resolve all types of denials (clinical, technical and administrative denials), including the facilitation of extensive reviews of the medical records, resolution of technical denials with Insurance companies for issues such as authorization of services, timely filing etc.

Identify the root cause of denials and work with denial and AR teams to implement effective strategies and process improvements, to reduce costly delays in payment.

IN THIS ROLE YOU WILL BE RESPONSIBLE FOR:

ENSURING DIRECT AND EXTENDED TEAM MEMBERS HAVE APPROPRIATE SKILLS AND TRAINING TO:

Validating denial reasons following Explanation of Benefits (EOB) review

Ensuring coding is accurate and reflects the denial reasons.

Coordinating with the Clinical Resource Center (CRC) for clinical consultations or account referrals when necessary,

Generating appeals based on the dispute reason and contract terms specific to the payer, to include online reconsiderations.

Following specific payer guidelines for appeals submission.

Escalating exhausted appeal efforts for resolution.

Working payer projects as directed.

Researching contract terms/interpretation and compile necessary supporting documentation for appeals, Terms & Conditions for account adjudication issues, and referral to refund unit on overpayments.

MANAGEMENT RESPONSIBILITIES:

Examine and work with client to improve accuracy of adjudication systems, to ensure these are working properly to efficiently adjudicate claims. This includes examination of Billing and AR function processes to minimize denials

Perform research and makes determination of corrective actions and takes appropriate steps to code and route account appropriately.

Analyzing payer performance and providing reports (including bulk issues) to client and internal operations Performs elevated level contract overview to ensure accuracy of contract terms and conditions.

Solid understanding of reimbursement methodologies to review variances to expected reimbursement (debit and credit balances) based on established guidelines.

Ability to analyze, trend and escalate issues as needed to the appropriate stakeholders. Prepare inventory of accounts to provide client with clean actionable issues to drive payer results.

* Interpret required reports (daily, weekly, monthly) to ensure optimum revenue recovery from claims.

* Coordinate efforts with client to drive changes in auto adjudication, aging and cycle time.

* Lead and participate in meetings as needed.

* Provide feedback to internal operations and client regarding payer trend status resolution.

* Provides concise documentation and reports to internal operations and client.

* Assist in special projects to drive desired payer results.

* Review bulletins and notifications from the payer on a timely basis and assess for business impact.

* Prepare related communications to notify stakeholders.

REQUIRED SKILLS FOR THIS ROLE INCLUDE:

Bachelors degree, preferably in Healthcare management

Minimum of 4 years experience as Denials manager in large multispecialty healthcare system

Prefer AAHAM certification as CRCE 1

10+ years of management experience that includes a staff of 5+ direct reports and 250+ total employees

10+ years of experience where you were responsible for setting standards and goals that met or exceeded company and client Service Level Agreements (SLAs).

5+ years of experience in a senior leadership role where you had to interact with external client stakeholders to plan and execute strategic initiatives.

5+ years of demonstrated experience developing and leading process improvement projects that drove operational efficiencies.

TRAVEL REQUIREMENTS:

INTERNATIONAL TRAVEL FOR UPTO 2 WEEKS EACH QUARTER TO PROVIDE TRAINING AND MENTORSHIP SUPPORT

This is a full-time salaried position with a group company within NTT DATA. Please note, 1099 or corp-2-corp contractors will NOT be considered. This position is only available to those interested in direct staff employment opportunities. We offer a full comprehensive benefits package that starts from your first day of employment.