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Posted Apr 18

Senior Counsel Appeals, Payer Specialization

HCA
Nashville, TN Full Time

Job Summary

The Senior Counsel, Appeals, is responsible for claim level review, escalation and resolution for all disputed denials that have remained unresolved or have been escalated under the Shared Service Center (SSC) operations pre-established protocols. This will also include engagement with HCA legal counsel and other corporate support departments upon production of demand letters and referral for outside counsel action, when warranted. This position will be critical in supporting the payer specialization strategy focused on denial cash conversion and ultimately avoidance. This position will be supported by appeals analysts and clerical support to ensure maximum productivity. Tracking large case volumes efficiently and effectively, with technology, while providing the highest levels of customer service and attention to details is required. Success in this position will be indicated by a high volume of throughput, escalation, and successful denial overturns.

Transition Duties (included but not limited to):

Responsible for building, supporting implementation and maintaining high quality processes in order to maximize net revenue.

Leverage new and existing technology capabilities accordingly and integrate into operational processes.

Manage transition and business continuity of processes between the Payer Specialization Team, the SSCs and other stakeholders; engage other corporate support departments such as Education, Project Management, HR, SMEs etc. accordingly.

Champion change management programs, with strong focus on effective and timely communication to the Payer Specialization Team, SSCs, corporate departments, payers and other stakeholders.

Operational Duties (included but not limited to):

Lead in the resolution of disputed, denied claims for specific payers.

Author complex contractual appeals and demand letters to insurance companies.

Lead the process for referral of disputed denial inventory trends, meeting certain thresholds, to outside counsel.

Engage accordingly with the Parallon Dispute Resolution Team, outside counsel and ensure collaboration with HCA stakeholders occurs regarding litigation and other legal actions.

Review and apply contract language and rates as necessary to resolve denied claims.

Utilize payer administrative manuals to dispute denied claims.

Utilize computer programs and software to ensure assigned cases and tracked and monitored in an efficient and effective manner.

Communicate with provider representatives (call, e-mail and/or meetings) to resolve complex claim and appeal issues.

Assist the Payer Specialization Team in denial avoidance and cash conversion strategies through the development of new and innovative legal and procedural arguments and tools.

Maintain and apply understanding of federal, state and local rules and regulations impacting denials and appeals.

Maintain and apply understanding of HCA / Parallon policies and procedures and work protocols impacting denials and appeals.

Maintain an understanding of DRG, per diem, case rates and other relevant insurance reimbursement and contract structures.

Apply provider specific reimbursement methodologies, payment policies and provider contracts to each disputed claim in process.

JD from accredited law school.

Minimum ten (10) years healthcare legal experience; preferably with five (5) years in third party payer dispute resolution.

License to practice law in good standing

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