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 assurance in a healthcare setting.
• Knowledge of Los Angeles Department of Public Health, Department of Mental Health and Joint Commission standards preferred.

LICENSES/CERTIFICATES

None

SETTING

Tarzana Treatment Centers, Inc. is a non-profit corporation, which provides behavioral healthcare services, including chemical dependency.

EQUAL OPPORTUNITY EMPLOYER

Tarzana Treatment Centers, Inc. does not discriminate as to age, race, nationality, religion, gender, sexual orientation and disability in its hiring practices.

ADA REQUIREMENT

Tarzana Treatment Centers, Inc. supports the Americans with Disabilities Act. Discrimination is prohibited in all aspects of employment against disabled persons, who, with reasonable accommodations, can perform the essential functions of a job.