Job Description

Locations: Gainesville, Florida

Categories: Office and Clerical

Req ID: 67902

Overview

Work remotely while using your denial management expertise to make a direct impact on healthcare operations.

💻 Work Style: Remote

📍 Location Requirement: Must reside in an approved state (FL, GA, PA, NC, SC, TN, or TX)

🕒 FTE: Full-Time (1.0 FTE)

Responsible for maintaining low denial rates and optimizing reimbursement across the enterprise by ensuring high coding standards and effective denial management practices. Leads and supports initiatives to improve coding accuracy, reimbursement outcomes, and appeal turnaround times.

Performs in-depth analysis of denial trends, including Epic system edits, coding validation, Charge Description Master (CDM) processes, authorization trends, and payer denials. Identifies opportunities for performance improvement and implements strategies to enhance revenue cycle outcomes.

Educates departments on appropriate charging, billing, and coding practices to ensure regulatory compliance. Collaborates with Managed Care, Compliance, and operational teams to resolve complex issues with departments and payers, driving sustainable improvements in reimbursement and denial prevention.

Responsibilities

Key Responsibilities

• Manages clinical denials from clinical denial work queues, including claim resubmission, authorization verification, payer claim reprocessing, claim reconsiderations, and appeals.
• Works closely with the Managed Care team and payers to reduce denials and increase reimbursement.
• Develops recommendations for coding and documentation process improvements based on denial analysis and coding guidelines.
• Completes all tasks within productivity and accuracy standards, including meeting the assigned productivity goal of 30 worked accounts in an 8-hour scheduled work period with a 98% accuracy rate from assigned denial work queues.
• Uses assigned coding software, NCCI, ICD-10, CPT, HCPCS, and CMS coding guidelines to accurately review, code, and correct accounts.
• Collaborates with department managers to report, track, and resolve denials. Assists with investigations and audits to correct charging, coding, and billing compliance errors, including identifying root causes, tracking trends, and reporting findings for appropriate follow-up.
• Works multiple assigned payer work queues, including Medicare, Medicaid, government payers, commercial payers, Medicare Advantage plans, and other assigned payers.
• Researches payer denials related to authorization, medical necessity, non-covered services, coding, and billing that result in denials and payment delays. Initiates timely appeals with insurers to prevent timely filing denials.
• Submits detailed, customized reconsiderations and appeals to payers based on medical record review and established policies and procedures.
• Identifies denial patterns and escalates findings to management with sufficient information to support additional follow-up and root cause analysis.
• Reviews payer communications to identify reimbursement risks related to medical policies and prior authorization requirements.
• Reviews coding, applies modifiers, corrects diagnosis sequencing, and adds or removes codes as appropriate in accordance with coding guidelines to resolve coding denials.
• Reviews and adjusts charges as appropriate according to charging, documentation, and billing guidelines.
• Partners with departments to educate staff, improve processes, reduce denials, minimize charging errors, and decrease authorization-related denials.
• Analyzes denied claims to identify root causes and reimbursement issues.

Qualifications

Education

• High School Diploma or GED required.
• One of the following coding certifications required: CPC, COC, RHIT, RHIA, or CCS.

Experience & Skills

• One (1) to two (2) years of coding experience required.
• One (1) to two (2) years of denial management and/or insurance-related experience required.