Compliance & Resolution Specialist

Department: Consumer Division
Direct Report: Missy Conley, Director Consumer Division
Sec. Report(s): Jeanne Woodward, Vice President Consumer Division
Location: Roanoke, VA.

POSITION SUMMARY

The Compliance & Resolution Specialist is responsible for direct negotiations and resolutions (verbal followed by written) with the facility/provider to obtain a signed confirmation agreement letter or corrected bill. The Compliance & Resolution Specialist responds to appeals submitted by facility. The Compliance & Resolution Specialist consults with the Director of Consumer Claims to meet the financial goals established for each client. The Compliance & Resolution Specialist assists the Consumer Division on special client projects.

DUTIES AND RESPONSIBILITIES

Specific Duties Include:

  • Preparation for Resolution (Time Estimate)
    • Conduct an analysis of all system documents related to claim review performed by analyst
    • Research facility for leverage (Uninsured discounts/other info on website to support our dispute)
    • Develop a strategic plan (outline) with which to initiate dialogue with the facility
  • 1st Approach (1-5 Business Days) First call should be within 24hrs of receiving claim. Contact should be Director/Manager of billing department
  • Introduction (See draft documents)
  • Discuss some of the non-compliant issues identified during the review of the itemized billing statement(s)
  • If applicable, discuss any CIA or HAC issues, beginning with the most recent. Determine if there are repetitive CIA or HAC issues within a category
  • If applicable, discuss fair and reasonable price after the non-billable charges (out-of-network claims only)
  • Propose a confirmation agreement letter, expires in 3-5 business days (extend if kept informed)
  • If considered, fax proposed confirmation agreement letter for signature along with report (Direct fax, or email)
  • Call to confirm fax received
  • Make notes in system, including voice recording of conversation

 

  • 2nd Approach (1-5 Business Days)
    • No success, fax provider a detailed Explanation of Review report (EOR) to a specific person.
    • Call to confirm fax received and kindly request an expeditious review with an estimated time.
    • Immediately communicate to the specific individual both verbally and in writing (fax, email, both), that a written denial response, inclusive of an explanation identifying the reason(s) for the denial decision of each item in disagreement is required for an appeal. The written denial response should be received within five (5) business days (If the state guidelines allow a maximum of 45 to issue a response, follow up every five [5] business days. ).
    • Discuss nurse auditor cannot address the compliance issues. We are not disputing medical records as to whether the item was ordered or performed. The items are related to charges that are not billable to patient and/or insurance company. The disputed charges should be addressed by the facility’s Compliance officer.
    • Make notes in system, including voice recording of conversation
  • 3rd Approach (1-5 Business Days)
    • Escalate issue to the CFO
    • Develop letter with chain of events documentation
    • Contact CFO assistant to obtain fax to submit letter and documents to CFO
    • Call to confirm fax received and kindly request an expeditious review with an estimated time.
    • Make notes in system, including voice recording of conversation
  • Appeals Received (5 Business Days)
    • Scan appeals into system
    • Research facility sources used to support their appeal
    • Adjust Explanation of Review report (EOR) to reflect reversals
    • Draft detailed response to facility appeal letter, including support attachments
    • Obtain necessary sources from paralegal
    • Obtain approval from Director of Hospital Accounts prior to sending response letter
    • Fax/email Appeal response letter
    • Scan fax confirmation into system
    • Make notes in system, including voice recording of conversation
  • Failed Resolution
    • Write chain of event notes in system forward to Director of Consumer Division
    • Director of Consumer Division will contact client to determine next steps
  • Settled Accounts
    • Scan signed confirmation agreement letter into system
    • Notify Claim Closing Analyst of settlement
    • Handle other settlement issues as needed

MINIMUM STANDARD REQUIREMENTS, SKILLS, AND ABILITIES

  • Two years of experience in negotiations, healthcare compliance
  • Knowledge in Medicare regulations and other billing guidelines
  • Excellent skills in communications, critical thinking, conflict resolution
  • Excellent written and verbal communications skills
  • Two years’ experience working in excel and access programs

INTENT AND FUNCTION OF JOB DESCRIPTIONS

Job descriptions assist organizations in ensuring that the hiring process is fairly administered and that qualified employees are selected. They are also essential to an effective appraisal system and related promotion, transfer, layoff, and termination decisions. Well-constructed job descriptions are an integral part of any effective compensation system.

All descriptions have been reviewed to ensure that only essential functions and basic duties have been included. Peripheral tasks, only incidentally related to each position, have been excluded. Requirements, skills, and abilities included have been determined to be the minimal standards required to successfully perform the positions. In no instance, however, should the duties, responsibilities, and requirements delineated be interpreted as all-inclusive. Management reserves the right to modify, add or remove essential functions as business needs warrant. Additional functions and requirements may be assigned by supervisors as deemed appropriate.

In accordance with the Americans with Disabilities Act, it is possible that requirements may be modified to reasonably accommodate disabled individuals. However, no accommodations will be made which may pose serious health or safety risks to the employee or others or which impose undue hardships on the organization.