Denial Specialst: 3 to 6 month project role.
Job Description:
1. Focus on working complex denials across multiple payers and/or regions
2. Conduct account history research as required, including navigating patient encounters and charts, researching charge and payment histories, determining historic account and claim status changes, and researching the payer remittance advice
3. Conduct follow up research on claims to review contract discrepancy and account balances. This may include attaching documentation, amending coverage/patient/encounter/provider/facility data, gathering additional information requests, and resubmitting corrected claims to ensure accurate and timely claim adjudication
4. Defend and appeal denied claims, including researching underlying root cause, collecting required information or documents, adjusting the account as necessary, resubmitting claims, and all appropriate follow up activities thereafter to ensure adjudication of the claim.
5. Must also be comfortable communicating denial root cause and resolution to leadership as needed
6. Responsible for aggregating the data that is required and then sending complete appeal packets for every level of appeal either by mail, fax or secured email.
7. Identify system loading discrepancies within the contract management system and refer to the Supervisor and/or Contract Associate Director for correction
8. Adhere to Compliance Plan and to all rules and regulations of all applicable local, state and federal agencies and accrediting bodies
9. Actively participate in outstanding customer service and accept responsibility in maintaining relationships that are equally respectful to all
10. Review and resolve accounts assigned via work lists daily as directed by management
11. Tracking and trending of rejection/denial issues
12. Recommendation of alternative contracting rates/terms with the goal to improve net revenue and/or ease the administrative burden associated with the contract terms
13. Meeting with payers to review methodology and assist in the determination of counter-proposals or settlement resolution.
14. Supporting the Manager and Director as needed
Miminal Requirements
- High School Diploma or Equivalant
- 5+ years in billing A/R Follow up, denaial Management and Appeals
- Proficient in payment review system, HIS and coding methodologies
- Advanced understanding of EOB's
- Intermediate knowledge of CPT, ICD-10 and HCPC's coding standards
- Understand CMS Memos and Transmttal
- Understand Medical Records, Professional claims and Charge Master
- Prefer EPIC experience
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