Under minimal supervision supports the continuous evaluation of the Department in alignment with Denver Health's financial, strategic, and operational initiatives and projects. Evaluates business processes, anticipates opportunities and challenges, identifies areas for improvement and makes data-driven recommendations. Coordinates and performs duties related to data acquisition and analysis for multiple projects simultaneously.
Conduct complex, in-depth analyses of claim payments and their methodology, identifying trends and patterns to ascertain cost avoidance/overpayment recovery opportunities. Apply root cause analysis to design and develop solutions to payment integrity opportunities/issues, and coordinate implementation efforts with internal stakeholders, as well as vendor(s) and providers as applicable. Ensure medical claims, records, and other documentation essential to claims submission and reimbursement are in compliance with state and federal guidelines, provider contracts, Denver Heath Medical Plan (DHMP) policy, national coding guidelines, and industry standards. Detect areas of billing inefficiencies, internal control weaknesses, and noncompliance and provide recommendations for corrective action plans
1.Conduct thorough analyses of all medical claims for adherence to state and federal guidelines, provider contracts, DHMP policy, national coding guidelines, and industry standards.
2.Review, research, and interpret medical record documentation, claims data, contractual guidelines, payment methodologies, and system adjudication to identify trends and patterns in complex claims payment data that result in recovery opportunities.
3.Create new, recurring and ad hoc reports to identify cost avoidance/overpayment opportunities using large data sets on multiple variables. Provide data, analyses, and recommendations to management on all findings affecting payments, including policy, contract issues, provider errors, pricing, and systems and claim processes.
4.Work with internal stakeholders to make any necessary technical updates to the system, policies, and procedures when necessary, as well as coordination of education to providers. Track and report progress of prospective and retrospective cost avoidance/overpayment recoveries.
5.Carry out new recovery concepts within the established deadlines with a high level of accuracy. Resolve any challenges made to the proposed cost avoidance/overpayment concepts throughout the organization, including, but not limited to, Provider Relations, Provider Contracting, Medical/Payment Policy and Legal.
6.Build strong stakeholder relationships and deliver solutions that meet stakeholders' expectations. Establish and maintain effective relationships, both internal and external.
7.Introduce best practices around post-payment recoveries.
8.Provide ongoing feedback to key internal stakeholders with the goal of improving internal payment control and reducing payment inconsistencies/overpayments.
9.Perform audit peer review analysis periodically to ensure quality of results and consistency in content, analytics, and adherence to department policies and procedures.
10.Develop written reports in accordance with reporting standards. Ensure that all audit findings, exceptions, and proposed adjustments to work papers/communication documents are well defined and explained or included in reports.
11.Manage appeals process with providers and third-party arbitrators when necessary.
12.Mentor less experienced staff.
13.Lead department projects and initiatives.
14.Other duties as assigned.
1. Two (2) years in data analysis, process improvement, or project management required.
Knowledge, Skills and Abilities
1. Must be able to work independently and meet schedules and deadlines. Ability to handle multiple tasks, simultaneously.
2. Exceptional ability to gather, understand, and utilize data to inform decisions and make recommendations. Excellent communication skills and ability to summarize detailed information in an organized, concise manner.
3. Strong analytical and problem-solving skills and ability to compile, categorize, calculate, audit, and/or verify data.
4. Project management skills, including the ability to manage several projects simultaneously while remaining flexible with changing priorities. Strong ability and comfort in presenting data, recommendations, and proposals to a wide variety of audiences and levels of leadership (both written and verbally).
Computers and Technology
1. Intermediate proficiency with Microsoft Office, specifically Excel required
2. Knowledge of relational databases (Microsoft SQL Server) and proficiency in SQL preferred
3. Experience in Healthcare Administration, Health Plan Operations, Managed Care, and/or Provider Services, revenue cycle/revenue integrity preferred. 4. Experience with Cognizant's QNXT preferred.
1. Demonstrated adaptability and flexibility to a rapidly moving business environment. 2. Ability to manipulate large data sets. 3. Ability to concisely communicate complex analyses to gain consensus across departments on overpayment items. 4. Ability to turn internal recommendations and industry concepts into potential cost-saving. 5. Knowledge of medical terminology, claim audit procedures, provider contracts, and claims processing procedures and guidelines. 6. Knowledge of medical claims data. 7. Knowledge of managed care practices. 8. Knowledge of Correct Coding Initiative (CCI) guidelines. 9. Knowledge of all claim forms and coding types, including UB-04, CMS 1500, ICD-9 and ICD-10, HCPC, revenue codes, NDC coding, HIPPA, HEIDIS, and NCQA. 10. Demonstrated ability to constructively and sensitively provide feedback to providers regarding federal and state coding, medical documentation and compliance guidelines, audit results, and risk areas. 11. Audit skills and the ability to interpret and apply federal and state regulations, as well as coding and billing requirements. 12. Demonstrated ability to review analytical, data, and audit findings to identify coding trends and risk areas. 13. Ability to interpret contract reimbursement schedules and policies. 14. Strategic and critical thinking skills. 15. Strong negotiation skills. 16. Ability to work effectively with a wide variety of people in individual and group settings. 17. Ability to manage diverse and deadline-oriented workflow. 18. Knowledge of diagnostic related groups (DRGs) and American Hospital Association Official Coding Guidelines. 19. Knowledge of current procedural terminology 20. Experience with Lean or Six Sigma.
1. Bachelor's Degree required. Concentration in business administration, finance, health care, or economics preferred.
Location Denver Health Medical Plan
All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.
Denver Health is an integrated, efficient, high-quality academic health care system that is considered a model for the nation. The Denver Health system includes the Rocky Mountain Regional Level I Trauma Center, a 525-bed acute care medical center, Denver's 911 emergency medical response system, 8 family health centers, 15 school-based health centers, the Rocky Mountain Poison and Drug Center, the Denver Public Health Department, an HMO, and The Denver Health Foundation.
As Colorado's primary safety net institution, Denver Health is a mission-driven organization that has provided more than $3.3 billion in care for the uninsured in the last ten years. Denver Health is a leader in performance and quality improvements and remains financially secure, in part, due to its nationally recognized implementation of lean principles in healthcare. Denver Health is a major resource to the community, serving approximately 185,000 individuals and 67,000 children a year.
Located just south of downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.
We strongly support diversity in the workforce and Denver Health is an equal opportunity employer (EOE).
"Denver Health is committed to provide equal treatment and equal employment opportunities to all applicants and employees. Denver Health is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class."
Internal Number: 3638
About Denver Health
Take your career to the next level at Denver Health, where we offer a robust benefits package and endless opportunities for growth. Denver Health is a nationally-ranked, locally-trusted, premier healthcare institution located in the heart of Denver, Colorado.Twenty-five percent of all Denver residents, or approximately 150,000 individuals, receive their health care here. We are known as an integrated health care system that encompasses multidisciplinary academic specialties, a community health system, a level I adult trauma center, pediatric emergency and urgent care center home to Denver Public Health and many of the nation’s leaders in medicine.