Denials Specialist

Position Summary

The Denials Specialist will be responsible for researching, analyzing, resolving and trending rejections and/or denials specific to the revenue cycle. This includes, but is not limited to, analyzing specific denial categories and codes, researching the underlying reason for the denial, rectifying the issue in the patient management system and ensuring that the claim is adjudicated.

The Denials Specialist should be able to identify potential process improvement opportunities and offer recommendations for correcting these issues. The Denials Specialist will be responsible for understanding how all of the various components of the revenue cycle can potentially cause a denial and possible solutions that may result from the interaction of these components. The Denials Specialist will have to be a problem solver and possess the ability to use the resources available to rectify a denial.

The Denials Specialist should be able to analyze Managed Care contracts and reconcile payments received. Contact insurance companies to have adjustments processed and/or file appeals if payments are not in accordance with the contract. The Denials Specialist will have direct interaction with all Managers and/or Department Heads regarding administrative issues related to rejections and/or denials.

• Focus on working complex denials across multiple payers and/or regions
• 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
• 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
• 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.
• Must also be comfortable communicating denial root cause and resolution to leadership as needed
• 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.
• Identify system loading discrepancies within the contract management system and refer to the Supervisor and/or Contract Associate Director for correction
• Adhere to Compliance Plan and to all rules and regulations of all applicable local, state and federal agencies and accrediting bodies
• Actively participate in outstanding customer service and accept responsibility in maintaining relationships that are equally respectful to all
• Review and resolve accounts assigned via work lists daily as directed by management
• Tracking and trending of rejection/denial issues
• Recommendation of alternative contracting rates/terms with the goal to improve net revenue and/or ease the administrative burden associated with the contract terms
• Meeting with payers to review methodology and assist in the determination of counter-proposals or settlement resolution.
• Supporting the Manager and Director as needed

• High school diploma, equivalent, or higher.
• 5 or more years of experience in billing, A/R follow up, denials management & appeal writing.

• Proficient in payment review systems, hospital information systems and coding methodologies.
• Strong quantitative, analytical and organizational skills.
• Advanced understanding of an Explanation of Benefits (EOB).
• Intermediate knowledge of CPT, ICD-10, and HCPCS coding standards.
• Understand CMS Memos and Transmittals.
• Understand medical records, professional claims, and the Charge master.
• Utilize and understand computer technology.
• Understand all ancillary charges and multi-specialty departmental functions.
• Communicate orally and in written form.
• Understand insurance terms and payment methodologies.
• Work…