Denials 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:

Primary role will include, but is not limited to, analyzing denials to determine the root causes and appealing denials to ensure that the healthcare provider or organization receives the appropriate reimbursement. Address and reduce future denials and communicate those with internal and client leadership.

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.

Key Responsibilities:

Review Denied Claims:

• Analyze denied claims to identify the root causes.
• Review insurance company policies and determine why claims were rejected.

Appeal Process:

• Develop appeal process by payer and identify any documentation needed for an appeal.
• Prepare and submit appeals to insurance companies to challenge denied claims.
• Communicate effectively with insurance companies, ensuring all necessary documentation is included.

Follow-Up:

• Track and monitor the status of appealed claims.
• Follow up regularly to ensure claims are processed and payments are made.

Documentation and Reporting:

• Maintain accurate records of claims and appeal activities.
• Generate reports related to denials and appeals for management review.
• Identify and communicate process gaps and how to reduce future denials.

Collaboration:

• Work closely with medical coders, billers, and providers to ensure correct coding and claim submission.
• Communicate with patients to resolve any outstanding issues related to claim denials.

Customer Service:

• Provide assistance to patients or providers who may have concerns about the denial or appeals process.

Adherence to Policies:

• Stay updated on insurance policies, state regulations, and compliance requirements.

Skills and Qualifications:

• 2+ years of experience in Healthcare Administration or Medical Billing & Coding.
• Knowledge of Healthcare Insurance and claim adjudication processes (Medicare, Medicaid, commercial insurance, etc.).
• Attention to Detail for identifying discrepancies in claim submissions.
• Strong Communication Skills for interacting with insurance companies, providers, and leadership.
• Problem-Solving Abilities to find solutions for denied claims.
• Familiarity with Medical Terminology and ICD-10, CPT codes.
• Proficiency with Medical Billing Software (e.g., Epic, Cerner, or other electronic health record (EHR) systems).

Educational Requirements:

• High school diploma or equivalent (required).
• A degree or certification in Healthcare Administration, Medical Billing, or related field may be preferred.
• Certification such as Certified Professional Coder (CPC) or Certified Medical Reimbursement Specialist (CMRS) is often a plus.

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.