Denial Specialist

Position Title: Denial Specialist Department: Quality Assurance Reports To: QA Supervisor POSITION SUMMARY Under the general supervision of the Quality Assurance Supervisor, the Denial Specialist focuses on managing contract patient denial status issues. The position will include audits of patient charts and documentation to support activities of agency in reducing denials. This position is also responsible for reporting on relevant measures and suggesting and coordinating improvement activities when directed.

HOURS : 40 per week, Monday - Friday Benefits Package Medical Insurance Dental Insurance Vision Care Plan Life Insurance Paid Holidays Flexible Spending Account (FSA) Paid Vacation Time Sick Time 401(k) Retirement Plan Competitive wages Stability and career advancement Continuing Education Opportunities CATEGORIES OF DUTIES Core Functions Reviews and reconciles denied authorizations from County and State funding sources and communicates with program staff to reverse denials to maximize revenue for the Drug Medi-Cal contract. Reviews ASAM assessments and relevant items in the SAGE and AVATAR systems to determine appropriate patient denial needs.

Reviews and triages denials to determine course of action for denied initial and re-authorizations with SAPC in SAGE (Authorization Form in SAGE and Misc. Note in SAGE) for all levels of care. Review and determine authorization resubmission, grievance/appeal completion, or write off for denied authorizations. Prepares grievance/appeal language for resubmission of authorization. Communicates with programs to identify missing documentation upon SAPC request and correspond with SAPC regarding ongoing denials as needed. Reviews appropriate reports for denial updates and communicates with programs about denial status, as necessary.

Requests program transfers and discharges to align with authorizations, as necessary. Inputs information into both SAGE and AVATAR systems as required for authorization needs. Communicates that information as needed. Works to automate the review, processing and reporting of denials throughout the organization. Acts as an expert on the denial process for the organization. Works with program staff to review admission and other relevant workflows to improve denial process and increase approvals. Attends trainings on authorization and denial processes and communicates findings throughout the organization, as necessary.

Conduct regular internal audits to identify trends and areas of development to increase compliance with SAPC and Joint Commission standards. Audit the content of clinical documentation such as assessments, treatment plans, and progress notes for quality, liabilities, and denial risks for both public and private funding sources. Performs other related duties as assigned by CEO, Director of Information Technology or QA Supervisor. EDUCATION/TRAINING/EXPERIENCE Bachelors degree or equivalent of at least 4 years experience. Prior experience in auditing and/or quality…

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