Job Description

Performs work related to clinical denial management. The individual is responsible for managing claim denials related to authorization, medical record requests, and coordination of benefits. The individual will actively manage, maintain, and communicate denial/appeal activity to appropriate stakeholders. The individual works independently to plan and organize activities that directly impact reimbursement. This role is key to securing reimbursement and minimizing organizational write-offs. The Denial Specialist conducts comprehensive reviews of the claim denial and account, to make determinations of what action to be taken to obtain reimbursement.

• Reviews denied claims to ensure coding was appropriate and make corrections as needed.
• Ensures billing and coding are correct prior to sending appeals or reconsiderations to payers.
• Investigate claims with no payer response to ensure claim was received by payer
• Strong understanding of payer websites and appeal process by all payers including commercial and government payers including VA, Tricare, Medicare, Medicaid, and Medicare/Medicaid Advantage plans
• Reviews and finds trends or patterns of denials to prevent errors
• Assists and confers with coding concerning any coding problems.
• Strong research and analytical skills. Must be a critical thinker.
• Stays current with compliance and changing regulatory guidelines.
• Demonstrates knowledge of coding and medical terminology in order to effectively know if claim denied appropriately and if appeal is warranted.
• Supports and participates in process and quality improvement initiatives.
• Achieve goals set forth by management regarding error-free work, transactions, processes and compliance requirements.
• Proactive resolution of issues and timely response to questions and concerns.
• Clearly document issues and resolution.
• Deliver timely required reports to the management team; initiates and communicates the resolution of issues, such as payor denial trends due to coding and billing errors.
• Responsible for working follow up work queues.
• Responsible for identifying missing payments, overpayments, and analyzing credits on accounts.
• Ability to successfully track and follow up on information requests.
• Work with the IPN Revenue Cycle Team to facilitate information and resolve charge questions.
• Other duties as assigned.

Shift: M-F, 8:30 AM - 5:00 PM

Requirements

• High School Diploma or GED required.
• Minimum of 3 years’ experience in a medical billing department with strong AR account follow-up, appeals, and coding knowledge is preferred.
• Demonstrated knowledge of and experience in professional medical billing, claim(s) processing, follow-up and appeals a must.
• Extensive knowledge on use of email, search engine, Internet; ability to effectively use payer websites; knowledge and use of Microsoft Products: Outlook, Word & Excel.
• Strong reasoning, critical thinking, analytical and mathematical skills.
• Ability to work independently, flexibly shifting from big picture to detailed tasks, with high productivity, and regularly execute deadlines.
• CPC certification is preference but not required.
• Cerner EHR working knowledge and experience a strong preference but not required.
• Must possess full range of body motion to pass basic FIT test for position to include walking, kneeling, standing, pushing, pulling, bending, stooping, reaching and sitting for extended periods of time.
• Must be able to lift and carry up to 25 pounds
• Manual dexterity needed for using a calculator and computer keyboard.