The Incumbent will focus on denials that impact the Revenue Cycle at OHSU and Community Connect Partners. This position serves as a primary contact for denials for the Centralized Managed Care department, which serves several key ambulatory practices. This role will be responsible to develop operational processes, system workflows and feedback loops to maintain and create efficient work processes integrating the requirements to mitigate denials. This individual will work with leadership staff to ensure these workflows are tested and implemented to reduce the chance for denials post service delivery. Another key component will be to manage the work queues where denials are routed.

This position will serve as a key support person on denials for the OHSU Healthcare mission. They will monitor denials for non-Intake Center departments. This support encompasses all ambulatory practices, the professional billing and PBS billing offices, hospital ancillary departments, and Central Registration. This support requires researching denials and best practices, evaluating the operations leading to the denials and determining an optimal mechanism for mitigating the risk, to achieve billing accuracy and limiting of denials received.

Centralized Managed Care Denials

• Facilitate monthly meetings with Hospital Billing, Centralized Managed Care leadership, Pharmacy and Clinic Staff
• Create and maintain an organized way for staff/leadership to follow up on outstanding denials
• Run denials and write-off reports
• Analyze root cause and present findings to HB, CM leadership and Clinic Leadership
• Triage accounts in the Follow-Up WQs
• Update charges with missing information
• Partner with the department Supervisor, Manager, Director and Billing Representatives to pursue all possible efforts to mitigate denial and achieve payment for services rendered or scheduled.
• Track activity and provide regular reports to leadership by department, payor and resolution reason
• Identify resources and work plans required to operationally initiate corrective action plans for any trends identified leading to denials.
• Deliver training to staff to ensure risk of denials is reduced to minimal level

• Coordinate activity with Client Service Analyst and Centralized Managed Care Team for synergistic possibilities between of each group and the Incumbent
• Work as part of the interdisciplinary team in planning and implementing new processes or systems at OHSU that may impact the possibility of receiving for pre-service authorizations and/or post service payments.
• Anticipate if payor challenges will occur by reviewing released newsletters, bulletins and websites. Develop proposals for mitigating or eliminating problems, including creating backup plans.

• Incumbent will attend and participate in Centralized Managed Care and Revenue Cycle meetings.

Attend provider workshops to ensure we have up to date info on payer guidelines.

Non-Centralized Denials

• Run denials and write-off report for all departments
• Receive and review denial reports from HB and PB for all departments
• Run reports to show denied referrals to identify trends by payor, department or other metrics
• Evaluate workflows leading to denials
• Determine best practice workflow and work with leadership to make changes as required to lower denial rate.
• Point of contact for HB billing when denials arise and action needs to be taken.
• Lead process improvement projects that will identify system or workflow changes required to optimize authorization and payment rates by reducing denial potentials. Maximize system efficiencies, reduce operational costs, improve accuracy and improve reimbursement outcomes.

Provide training to responsible staff which will reduce the risk of denials

Five years of experience with responsibility for program or project monitoring and coordination.
The experience must have included program evaluation responsibility.

A bachelor’s degree in Business Administration, Management, Public Administration, or a field
directly related to the position will substitute for two years of the required experience.

Experience:

• OHSU PAS and Managed Care training

• Strong understanding of Epic Practice management applications, medical office billing and registration processes

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  Epic Certification in Revenue Cycle application (Resolute PB or HB, Cadence, Prelude/ADT)