Yale New Haven Health
Outpatient Clinical Appeal Lead - Remote
Yale New Haven Health, New Haven, Connecticut, us, 06540
Outpatient Clinical Appeal Lead - Remote
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Outpatient Clinical Appeal Lead - Remote
role at
Yale New Haven Health
Overview To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient‑centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
EEO/AA/Disability/Veteran
Qualifications Bachelor's degree required. Master's degree related to health/governmental policy, regulatory science, law, etc. is preferred. Certification related to HIM activities is required (i.e., CCS, RHIA, CPC, COC, CIC, etc.).
Three to Five years' experience in Health Information Management, ICD‑10 Coding, Health IT or related healthcare or hospital‑based operations activities, including experience with audits and appeals. Ability to navigate medical records and other clinical documentation within Epic is essential. Basic understanding of clinical care or concepts is helpful.
HIM related certification is required, Certified Coding Specialist (CCS) credential from Ahima is preferred.
Demonstrated excellent oral and written communication skills. Knowledge of medical terminology and state and federal regulations regarding release of medical information. Excellent organizational skills. Strong computer skills. Ability to train new staff, identify and implement workflow improvement activities and develop and maintain organized reporting systems/structure.
Responsibilities
Support the revenue cycle operation of the health system and serve as subject matter expert of outpatient clinical audit and appeal functions.
Oversight of outpatient clinical audit/appeal function, ensuring timely submission and communication of audit/appeal responses between departments through the highest level of appeal.
Assist all team members as needed with complex audit/appeal issues and scenarios for timely submission of audits/appeals, contributing to the resolution of issues.
Assist all team members in identifying additional required medical record documentation ancillary systems to support the medical necessity of the services in question.
Conduct root cause analysis on denied cases and share themes with relevant areas. As needed, navigate complex payer requirements for greater insight.
Drawing on coding and clinical experience, support the development of thorough compelling clinical appeal letters.
Collaborate with various revenue and clinical departments throughout the health system to meet required deadlines and maintain timely oversight of clinical appeal activity.
Support leadership in communications with the legal office, compliance, payer strategy to ensure YNHHS is responding appropriately by contracted or regulatory terms.
Develop and maintain skills in ad hoc report development and coordinate departmental reporting of appeals for the facility’s delivery networks.
Regularly update reporting narrative for high level reporting and presentation, develop SBAR communications/memos as needed.
Analyze denial and appeal related activity for trends and outcomes. Regularly communicate updates and analysis to appropriate stakeholders using reports and other tracking.
Attend Connecticut Hospital Association (CHA) educational sessions pertaining to billing, coding, and denial related activity. Attend payer webinars related to denial and cost recovery programs.
Communicate any relevant information to teams and leadership. Monitor for continuing education opportunities related to clinical denials and appeals and coordinate attendance for the department.
Attend monthly payor meetings for escalation of unresolved appeals.
Maintain competency in current EMR System and proficiency in audit tracking systems.
Identify IT related issues and/or improvement opportunities and collaborate with relevant teams to troubleshoot, correct or implement new technical processes.
Accountability Accountable for timely and accurate dissemination of patient medical information and appeals to governmental and non‑governmental payers and regulatory entities in accordance with state and federal regulations (i.e., HIPAA), payer contract, and YNHHS Administrative policy. Accountable for data integrity related to area functions.
In personal and job‑related decisions and actions, consistently demonstrates the values of integrity, patient‑centered, respect, accountability, and compassion.
Complexity Reviews volumes of medical record requests and appeal opportunities to assist in the distribution of workload to teams to ensure efficient operations. Must deal effectively with internal and external customers. Inherent responsibility to promote and maintain good customer relations and to continually improve service. Determines, according to established governmental regulations and hospital guidelines, the availability and extent of medical information to be released. Exercises independent judgment in the release of requested information. Recognizes equipment, systems and procedural problems and takes appropriate action as needed. Represents department at conferences, committee meetings, and other venues pertaining to governmental audits and appeals.
Position Overview The Outpatient Clinical Audit/Appeal Lead will support the Clinical Audit/Appeals and Denial Prevention Management team with oversight of clinical audit and appeal activity inclusive of all payor types. Responsibilities include the organization of data and reporting of outpatient clinical audit/appeal volumes and outcomes, monitoring benchmarks and reviewing performance statistics, and identifying opportunities for workflow efficiency and effectiveness. The individual must be able to collaborate with all team members, insurance payors, including third party, and various departments throughout the health system relative to the clinical audit/appeal work.
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Outpatient Clinical Appeal Lead - Remote
role at
Yale New Haven Health
Overview To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient‑centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
EEO/AA/Disability/Veteran
Qualifications Bachelor's degree required. Master's degree related to health/governmental policy, regulatory science, law, etc. is preferred. Certification related to HIM activities is required (i.e., CCS, RHIA, CPC, COC, CIC, etc.).
Three to Five years' experience in Health Information Management, ICD‑10 Coding, Health IT or related healthcare or hospital‑based operations activities, including experience with audits and appeals. Ability to navigate medical records and other clinical documentation within Epic is essential. Basic understanding of clinical care or concepts is helpful.
HIM related certification is required, Certified Coding Specialist (CCS) credential from Ahima is preferred.
Demonstrated excellent oral and written communication skills. Knowledge of medical terminology and state and federal regulations regarding release of medical information. Excellent organizational skills. Strong computer skills. Ability to train new staff, identify and implement workflow improvement activities and develop and maintain organized reporting systems/structure.
Responsibilities
Support the revenue cycle operation of the health system and serve as subject matter expert of outpatient clinical audit and appeal functions.
Oversight of outpatient clinical audit/appeal function, ensuring timely submission and communication of audit/appeal responses between departments through the highest level of appeal.
Assist all team members as needed with complex audit/appeal issues and scenarios for timely submission of audits/appeals, contributing to the resolution of issues.
Assist all team members in identifying additional required medical record documentation ancillary systems to support the medical necessity of the services in question.
Conduct root cause analysis on denied cases and share themes with relevant areas. As needed, navigate complex payer requirements for greater insight.
Drawing on coding and clinical experience, support the development of thorough compelling clinical appeal letters.
Collaborate with various revenue and clinical departments throughout the health system to meet required deadlines and maintain timely oversight of clinical appeal activity.
Support leadership in communications with the legal office, compliance, payer strategy to ensure YNHHS is responding appropriately by contracted or regulatory terms.
Develop and maintain skills in ad hoc report development and coordinate departmental reporting of appeals for the facility’s delivery networks.
Regularly update reporting narrative for high level reporting and presentation, develop SBAR communications/memos as needed.
Analyze denial and appeal related activity for trends and outcomes. Regularly communicate updates and analysis to appropriate stakeholders using reports and other tracking.
Attend Connecticut Hospital Association (CHA) educational sessions pertaining to billing, coding, and denial related activity. Attend payer webinars related to denial and cost recovery programs.
Communicate any relevant information to teams and leadership. Monitor for continuing education opportunities related to clinical denials and appeals and coordinate attendance for the department.
Attend monthly payor meetings for escalation of unresolved appeals.
Maintain competency in current EMR System and proficiency in audit tracking systems.
Identify IT related issues and/or improvement opportunities and collaborate with relevant teams to troubleshoot, correct or implement new technical processes.
Accountability Accountable for timely and accurate dissemination of patient medical information and appeals to governmental and non‑governmental payers and regulatory entities in accordance with state and federal regulations (i.e., HIPAA), payer contract, and YNHHS Administrative policy. Accountable for data integrity related to area functions.
In personal and job‑related decisions and actions, consistently demonstrates the values of integrity, patient‑centered, respect, accountability, and compassion.
Complexity Reviews volumes of medical record requests and appeal opportunities to assist in the distribution of workload to teams to ensure efficient operations. Must deal effectively with internal and external customers. Inherent responsibility to promote and maintain good customer relations and to continually improve service. Determines, according to established governmental regulations and hospital guidelines, the availability and extent of medical information to be released. Exercises independent judgment in the release of requested information. Recognizes equipment, systems and procedural problems and takes appropriate action as needed. Represents department at conferences, committee meetings, and other venues pertaining to governmental audits and appeals.
Position Overview The Outpatient Clinical Audit/Appeal Lead will support the Clinical Audit/Appeals and Denial Prevention Management team with oversight of clinical audit and appeal activity inclusive of all payor types. Responsibilities include the organization of data and reporting of outpatient clinical audit/appeal volumes and outcomes, monitoring benchmarks and reviewing performance statistics, and identifying opportunities for workflow efficiency and effectiveness. The individual must be able to collaborate with all team members, insurance payors, including third party, and various departments throughout the health system relative to the clinical audit/appeal work.
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