Denials Management Legal Advisor in Altamonte Springs, FL at Adventist Health System

Date Posted: 11/9/2018

Job Snapshot

  • Job Schedule
  • Job Category
  • Date Posted:
  • Job ID:
  • Job Function
  • Travel
  • Shift
    1 - Day
  • AHS Zone
    1-Shared Services
  • Organization
    Adventist Health System Corporate Office

Job Description

Work Hours/Shift

Full Time, Monday-Friday

Adventist Health System Corporate Office

Be part of the Adventist Health System family.

Where you work matters. Working here is like being part of a family. Not just with those you serve, but also with your team members. It’s about making a difference, saving lives, and helping others live a fuller one. You’ll be joining a family of tens of thousands of team members who understand that what they do is bigger than healthcare. It is living out our mission to Extend the Healing Ministry of Christ and being there for someone every step of the way-body, mind, and spirit.

This is more than a career. It is a calling.

With hospitals and facilities in 9 states, you’ll have endless opportunities to take your talents, develop your skills, and grow as a professional in a place that truly cares about your success. If you are driven, compassionate, someone who always wants to go above and beyond because you care and believe what you do makes a difference – Adventist Health System is for you.

Under general supervision of the Executive Director of Denials Management, the Legal Advisor will handle large-scale patterns of denials and reimbursement issues through legal action to ensure appropriate reimbursement for the medical services provided by Adventist Health System. This role involves working with other departments within the denials management team to identify payment issues and collect necessary evidence. The Legal Advisor will act as a liaison between AHS and payers, resolving issues through direct communication with payer representatives and legal counsel, and representing the interests of AHS in such disputes. This position requires navigating state and national health law frameworks and payer contracts, and leveraging interpretation of policies to support appeals with medical need and legal justification, to ultimately maximize revenue realization. Adheres to AHS Compliance Plan and to all rules and regulations of all applicable local, state and federal agencies and accrediting bodies.

What you will be responsible for:
  • Reviews denials data and collaborates with Physician Advisors, denials management staff, patient financial services, utilization review, managed care, and other appropriate teams to identify and remediate identified problem areas in reimbursement and denials.
  • Communicates regularly with appropriate stakeholders to address reimbursement and denial issues and collects and prepares necessary documentation for legal action.
  • Represents AHS in legal disputes with payers to receive proper reimbursement for services rendered.
  • Utilizes medical documentation provided by clinical counterparts, business rationale from billing/finance and other departments, and payer contracts & policies to provide accurate clinical and legal justification to combat denial and underpayment disputes.
  • Communicates with payer representatives and provides them necessary documents in a timely manner when resolving disputes.
  • Supports and attends payer JOC (Joint Operational Committee) calls and meetings as needed.
  • Keeps denial management leadership informed of status and outcomes of high dollar disputes, and provides guidance moving forward.
  • Stays abreast of policies and regulations governing payers as well as AHS contractual language.
  • Strives towards meeting and exceeding productivity and quality expectations to align performance with assigned roles and responsibilities. Escalates concerns or difficulties in meeting performance expectations in a timely manner for management action.
  • Maintains a positive working relationship with internal staff and external providers, payer representatives, and clinicians and acts in a professional, courteous manner at all times.
  • Performs other relevant duties within scope of work as assigned by management.
What you will need:
  • Juris Doctor degree from an ABA-approved law school
  • Minimum of 10 years of health care contract experience
  • Minimum of 7 years of leadership experience
  • Active membership and good standing of the Bar
  • Licensed to practice law in the state of Florida and other states with AHS entities
  • Proficient understanding of U.S. health services systems and healthcare legislation

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

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