The incumbent will focus on managing claim denials affecting the Revenue Cycle at OHSU and its Community Connect Partners. Serving as the primary contact for denials within the Centralized Managed Care department, this role supports managed care denial review across the system. Responsibilities include developing operational processes, system workflows, and feedback mechanisms to enhance efficiency and address denial mitigation requirements. The individual will collaborate with leadership to ensure these workflows are thoroughly tested and implemented, minimizing the likelihood of denials following service delivery.

 

A crucial aspect of this role involves overseeing the system work queues where denials are processed. The incumbent will play a vital support role in addressing denials in alignment with the OHSU Healthcare mission. This support spans all ambulatory practices, professional billing and hospital billing offices, hospital ancillary departments, inpatient services, and central registration. The position requires researching denials, evaluating operational processes that lead to denials, and identifying effective strategies and best practice, for risk mitigation to ensure billing accuracy and reduce the incidence of denials.

Centralized Managed Care Denials

• Facilitate monthly meetings with Hospital Billing, Centralized Managed Care leadership, Community Partner leadership, Pharmacy, and Clinic Staff to discuss denial trends and strategies.
• Develop and maintain an organized tracking system for staff and leadership to follow up on outstanding denials efficiently.
• Generate and analyze denials and write-off reports to identify patterns and areas for improvement.
• Conduct root cause analyses and present findings to Hospital Billing, Centralized Managed Care leadership, and Clinic Leadership for informed decision-making.
• Triage accounts in the Follow-Up Work Queues to prioritize denial resolution efforts.
• Update charges with any missing information to ensure accuracy in billing.
• Collaborate with department Supervisors, Managers, Directors, and Billing Representatives to explore all avenues for mitigating denials and securing payment for services rendered or scheduled.
• Track denial resolution activities and provide regular reports to leadership, detailing performance by department, payor, and resolution reason.
• Identify necessary resources and develop work plans to implement corrective action plans addressing trends leading to denials.
• Deliver training sessions to staff aimed at minimizing denial risks and enhancing overall billing practices.
• Coordinate activities with Client Service Analysts and the Centralized Managed Care Team to leverage synergistic opportunities between teams.
• Engage as part of an interdisciplinary team to plan and implement new processes or systems that may affect pre-service authorizations, reimbursements, and post-service payments.
• Anticipate potential payor challenges by reviewing industry newsletters, bulletins, and websites. Develop proposals to mitigate or eliminate issues, including creating contingency plans.
• Attend and actively participate in Centralized Managed Care and Revenue Cycle meetings to stay aligned with organizational goals.
• Participate in provider workshops to ensure up-to-date knowledge of payer guidelines and requirements.

Non-Centralized Denials

• Generate and analyze denials and write-off reports across all departments to identify performance metrics.
• Review and assess denial reports received from Hospital Billing (HB) and Professional Billing (PB) for all departments to ensure comprehensive understanding.
• Run reports to track denied referrals, analyzing trends by payor, department, or other relevant metrics to inform decision-making.
• Evaluate existing workflows that contribute to denials, identifying bottlenecks and areas for improvement.
• Collaborate with leadership to develop best practice workflows aimed at reducing denial rates through necessary changes.
• Serve as the primary point of contact for billing inquiries regarding denials, facilitating timely action and resolution.
• Lead process improvement initiatives that identify necessary system or workflow changes to enhance authorization and payment rates, focusing on minimizing denial risks. Aim to maximize system efficiencies, reduce operational costs, improve accuracy, and enhance reimbursement outcomes.
• Provide training to relevant staff members to ensure best practices are followed and to further reduce the risk of denials.
• Other duties as assigned.

• At least 5 years of experience, with responsibility for program or project monitoring and coordination focused on revenue cycle in an ambulatory care and/or physician practice setting with responsibility for managed care and other revenue cycle management.

• This experience must have included program evaluation responsibility.

• Bachelor’s degree in business administration, management, public administration or a related field will substitute for 2 years of the required experience.

• Demonstrated leadership skills.

• Demonstrated organizational skills.

• Demonstrated revenue cycle, financial analysis and project management skills.

• Demonstrated communication, interpersonal and conflict resolution skills.

• Demonstrated skills of working in partnership with multiple planning groups, including physicians.

• Bachelors degree in a related field.
• OHSU PAS and Managed Care training.
• Strong understanding of Epic Practice management applications, medical office billing and registration processes
• Epic Certification in Revenue Cycle application (Resolute PB or HB, Cadence, Prelude/ADT).

Benefits

• Healthcare covered 100% for full-time employees and 88% for dependents.
• $25K of term life insurance provided at no cost to the employee.
• Two separate above market pension plans to choose from.
• Vacation - up to 200 hours per year depending on length of service.
• Sick Leave - up to 96 hours per year.
• 8 paid holidays per year.
• Substantial Tri-Met and C-Tran discounts.
• Childcare service discounts.
• Employee discounts to local and major businesses.
• Additional Programs including Tuition Reimbursement and Employee Assistance Program.

Oregon Health & Science University values a diverse and culturally competent workforce. We are proud of our commitment to being an equal opportunity, affirmative action organization that does not discriminate against applicants on the basis of any protected class status, including disability status and protected veteran status. Individuals with diverse backgrounds and those who promote diversity and a culture of inclusion are encouraged to apply. To request reasonable accommodation contact the Affirmative Action and Equal Opportunity Department at 503-494-5148 or aaeo@ohsu.edu.