Utilization Rev Appeals Spec

January 23, 2024

Job Description

Summary

Why Join Michigan Medicine’s Hospital Billing Audits & Appeals (HBAA) Department…

The Audit and Appeals Specialist has a strong knowledge of medical appeal and audit practices for both the inpatient and outpatient populations. They are knowledgeable about insurance requirements and medical billing practices. The Appeals Specialist will collaborate with multiple departments to maintain compliance with CMS regulations and third party payer requirements. They appeal based on medical necessity, level of care, administrative and outpatient denials. They manage and respond to Medicare, Medicare Advantage, Varis, Medicaid and other various commercial audits. The Appeals Specialist will communicate and provide education, with information gained from the audits and appeals they manage, to the appropriate department to ensure first time quality.

Perks And Benefits To Look Forward To
• 2:1 match on retirement savings
• Excellent medical, dental, and vision coverage starting on day one of employment
• Generous Paid Time Off (PTO) and paid holidays

Mission Statement

Michigan Medicine improves the health of patients, populations and communities through excellence in education, patient care, community service, research and technology development, and through leadership activities in Michigan, nationally and internationally. Our mission is guided by our Strategic Principles and has three critical components; patient care, education and research that together enhance our contribution to society.

Why Join Michigan Medicine?

Michigan Medicine is one of the largest health care complexes in the world and has been the site of many groundbreaking medical and technological advancements since the opening of the U-M Medical School in 1850. Michigan Medicine is comprised of over 30,000 employees and our vision is to attract, inspire, and develop outstanding people in medicine, sciences, and healthcare to become one of the world’s most distinguished academic health systems. In some way, great or small, every person here helps to advance this world-class institution. Work at Michigan Medicine and become a victor for the greater good.

What Benefits can you Look Forward to?
• Excellent medical, dental and vision coverage effective on your very first day
• 2:1 Match on retirement savings

Responsibilities*
• The Audit and Appeals Specialist works in Revenue Cycle. They work closely with inpatient, outpatient and professional billing. They collaborate with many departments outside of Revenue Cycle including Care Management, Registration, MiVisit Business services, clinics and ancillary departments.
• Review patient medical records and utilize clinical and regulatory knowledge as well as knowledge of payer requirements to determine reasons for denials and what type of appeal is required.
• Make appeal referrals to both internal and external physician advisors. Utilize knowledge of third party regulations to initiate interventions
• Collaborate with physicians, PA?s, Compliance department and Health System Legal office to ensure complete and accurate information on all appeal letters.
• Make recommendations for further appeal, referrals to UMHS contracting and/or legal offices.
• Utilize knowledge of CMS regulations, OPPS coding for surgical procedures and the Medicare inpatient only list to ensure accurate reimbursement.
• Review readmissions and apply payer guidelines. Combine accounts as necessary prior to release of claims.
• Monitor Medicaid retrospective eligibility cases, complete required forms, track retrospective authorizations or need for appeal
• Utilize payer specific communication protocols and document all contacts, including outcomes to assure appropriate payment of claims for approved services. Document all denied services, appeal dates and maintain records of correspondence throughout the appeal process.
• Complete and maintain MiChart, ADT and Billing workqueues.
• Collaborate with other revenue cycle departments. Attend and participate in departmental and interdisciplinary meetings and committees. Incorporate learning into operational activities as appropriate.
• Assist in the overall achievement of the objectives and financial goals of Michigan Medicine

Required Qualifications*
• An Associate degree in Health Information Technology OR Associate degree RN
• RHIT certification
• At least 2-5 years of recent experience in Utilization Management, Appeals Management or Case Management
• Current/active certification/licensing through professional association
• Strong communication skills, with emphasis on excellent writing skills
• Required computer skills: Microsoft Office applications (i.e., Word, Excel), EHR. Ability to use and master multiple computer systems and applications.
• Ability to maintain confidentiality according to HIPPA regulations.
• Detail-oriented, organized, strong problem-solving skills, strong investigative skills, critical thinking skills and ability to be self-directed and work independently

Desired Qualifications*
• Experience with a case management/utilization management software program and EPIC (MiChart)
• Knowledge of University policies and procedures
• Payer appeals experience in a healthcare setting
• Knowledge of third party payer regulations and reimbursement methodologies and payer audit and appeal requirements
• Strong interpersonal and written communication skills, problem solving, decision making, and negotiation skills are necessary.
• Must have demonstrated the ability to work well with physicians and other health care providers
• Able to write clearly and informatively; edit work for spelling and grammar; able to interpret written information

Work Schedule

This is a full-time, 40 hour/week, exempt position. We are open for business between the hours of 5:30AM and 6:00PM Monday-Friday. The typical work schedule would be set within this timeframe.

Work Locations

Work From Home Position Or Alternate

KMS Building

3621 S. State Street

Ann Arbor, MI 48108

Background Screening

Michigan Medicine conducts background screening and pre-employment drug testing on job candidates upon acceptance of a contingent job offer and may use a third party administrator to conduct background screenings. Background screenings are performed in compliance with the Fair Credit Report Act. Pre-employment drug testing applies to all selected candidates, including new or additional faculty and staff appointments, as well as transfers from other U-M campuses.

Application Deadline

Job openings are posted for a minimum of seven calendar days. The review and selection process may begin as early as the eighth day after posting. This opening may be removed from posting boards and filled anytime after the minimum posting period has ended.

U-M EEO/AA Statement

The University of Michigan is an equal opportunity/affirmative action employer