Description

About Us Here at Baylor Scott & White Health we promote the well-being of all individuals, families, and communities. Baylor Scott and White is the largest not-for-profit healthcare system in Texas that empowers you to live well.

Our Core Values are:

• We serve faithfully by doing what's right with a joyful heart.

• We never settle by constantly striving for better.

• We are in it together by supporting one another and those we serve.

• We make an impact by taking initiative and delivering exceptional experience.

Benefits Our benefits are designed to help you live well no matter where you are on your journey. For full details on coverage and eligibility, visit the Baylor Scott & White Benefits Hub to explore our offerings, which may include:

• Immediate eligibility for health and welfare benefits

• 401(k) savings plan with dollar-for-dollar match up to 5%

• Tuition Reimbursement

• PTO accrual beginning Day 1

Note: Benefits may vary based upon position type and/or level.

Job Summary The Denial Resource Center Appeal Support Specialist ensures complete and accurate appeals of denied claims are submitted on time. The specialist processes reconsiderations, redeterminations, appeals, and resubmissions of appeals. They also handle State Complaint letters, legal submissions to the Administrative Law Judge, and requests for Coordination of Benefits or Patient Consent letters. The specialist also writes non-clinical appeals that meet specific criteria.

Essential Functions of the Role

• Ensures all documentation submitted to the payer is true and accurate. Completes necessary forms and submits documentation to the correct provider portal, payer address, or fax number. Ensures submissions are sent to be received by the payer before the deadline.

• Completes resubmissions of previously submitted redeterminations and appeals. Reviews account notes to determine the correct resubmission method. Compiles a resubmission letter with details of previous submissions. Resubmits the appeal to the payer.

• Performs non-clinical appeals on low dollar, outpatient, pre-auth denials. Reviews the patient's records to verify the denial reason and if authorization was required or obtained. Completes an appeal letter with denial details and information to support overturning the claim. Pulls medical records and supporting documentation from previous hospitalizations, care episodes, or physician office records to support the appeal.

• Compile documentation to submit on accounts identified through Insurance Ops review. These accounts are escalated to the Managed Care Legal team.

• Requests complete medical records and notarized affidavits from the Health Information Management department as needed.

• Processes all incoming correspondence and ensures distribution to the correct teams. Ensures all outgoing correspondence is taken to the mail room daily.

• Document submission information and appeal findings in the accounts receivable system. Ensure all accounts transfer accurately to the next team once complete.

• Participates in pertinent meetings and huddles to share trends identified with leadership.

Key Success Factors

• Knowledge of office procedures.

• Able to maintain the confidentiality of sensitive and confidential information obtained through the course of completing assignments.

• Skilled in document management, including sorting and filing techniques, and records retention to maintain accurate records.

• Able to communicate thoughts clearly; both verbally and in writing.

• Must be able to read, write and follow instructions and flow chart protocols.

• Able to stay calm and helpful under stress. Takes appropriate steps to resolve issues.

• Able to work carefully, with a high attention to detail.

• Advanced computer skills, including but not limited to: typing, information security, electronic medical documentation, hand held scanning and email.

• Proficient with MS Office suite including Word, Excel, PowerPoint.

Belonging Statement We believe that all people should feel welcomed, valued and supported.

QUALIFICATIONS

• EDUCATION - H.S. Diploma/GED Equivalent

• EXPERIENCE - 2 Years of Experience