Medical AR Denials and Edits Specialist

About Us:

Our purpose is to help clients exceed their financial health goals. Across the reimbursement cycle, our scalable solutions and clinical expertise help solve programmatic needs. Enabling our teams with leading technology allows analytics to guide our solutions and keeps us accountable achieving goals. 

We build long-term careers by investing in YOU. We seek to create an environment that cultivates your professional development and personal growth, as we believe your success is our success.  

JOB SUMMARY:

ESSENTIAL DUTIES AND RESPONSIBILITIES: 
Note: The essential duties and responsibilities below are intended to describe the general duties and responsibilities of this position and are not intended to be an exhaustive statement of duties. This position may perform all or most of the primary duties listed below. Specific tasks, responsibilities or competencies may be documented in the Team Member’s performance objectives as outlined by the Team Member’s immediate Leadership Team Member.

Essential Functions: 

Note: The essential duties and primary accountabilities below are intended to describe the general content of and requirements of this position and are not intended to be an exhaustive statement of duties. Incumbents may perform all or most of the primary accountabilities listed below. Specific tasks, responsibilities or competencies may be documented in the incumbent’s performance objectives as outlined by the incumbent’s immediate supervisor or manager. 

• Performs duties as assigned which includes interacting with insurance plans, patients, physicians, attorney’s and fellow Team Members as needed. 

• Verifies or obtains patient eligibility and/or authorization for healthcare services performed by searching payer web sites or client eligibility systems, or by conducting phone conversations with the insurance carrier or healthcare providers.  

• Updates patient demographics and/or insurance information in appropriate systems.  

• Conducts research and appropriately statuses unpaid or denied claims.   

• Monitors claims for missing information, authorization and control numbers (ICN//DCN).  

• Research EOBs for payments or adjustments to resolve claims.  

• Contacts payers by phone or through written correspondence to secure payment of claims.  

• Accesses client systems for information regarding received payments, open claims and other data necessary to resolve claims.  

• Follows guidelines for prioritization, timely filing deadlines, and notation protocols within appropriate systems.  

• Secures medical documentation as required or requested by third party insurance carriers.  

• Obtains billing guidelines and requirements by researching provider billing manuals.   

• Writes appeal letters for technical appeals.  

• Verifies accuracy of underpayments by researching contracts and claims data.  

• In the event of an authorization, coding, level of care and/or length of stay denial, prepares claims for clinical audit processing.   

Knowledge, Skills & Abilities: 

• 3+ years of accounts receivable experience within the healthcare revenue cycle.  

• Must have a minimum of 2 years’ experience with Medi-Cal. 

• 2+ years of experience with healthcare and/or insurance billing and processing. 

• Experience with professional physician and hospital facility claims. 

• Ability to read and interpret an EOB. 

• Knowledge and understanding of UB04 and HCFA 1500 forms. 

• High School diploma 

• Proficiency with Outlook, Excel, and word. For example; must be able to manage email, outlook calendar and tasks. Must be able to do basic formulas such as, add, subtract, multiplication, etc.  

• Ability to communicate in a professional and clear manner. 

• Strong interpersonal skills 

• Ability to work independently, have analytical and critical thinking skills. 

PHYSICAL DEMANDS:
Note: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions as described. Regular eye-hand coordination and manual dexterity is required to operate office equipment. The ability to perform work at a computer terminal for 6-8 hours a day and function in an environment with constant interruptions is required. At times, Team Members are subject to sitting for prolonged periods. Infrequently, Team Member must be able to lift and move material weighing up to 20 lbs. Team Member may experience elevated levels of stress during periods of increased activity and with work entailing multiple deadlines.
A job description is only intended as a guideline and is only part of the Team Member’s function. The company has reviewed this job description to ensure that the essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.