Denials Specialist

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Basic Function and Scope of Responsibilities:

This job is responsible for corresponding with health insurance payers to address and resolve outstanding insurance balances related to coding denials in accordance with established standards, guidelines and requirements. An incumbent conducts follow-up process activity through review of medical records and contact with providers, phone calls, online processing, fax and written correspondence, leveraging work queues to organize work efficiently. Work also includes reviewing insurance remittance advices, researching denial reasons and resolving issues through well-written appeals. Work requires proactive troubleshooting, significant attention to detail and the application of analytical/critical thinking skills to analyze denials and reimbursement methodologies and bring timely resolution to issues that have a potential impact on revenues. In addition, the incumbent must be able to communicate effectively with payer representatives and maintain professional communication with team members in order to support denials resolution.

Principal Responsibilities:

–        Follows-up with insurance payers to research and resolve unpaid insurance accounts receivable; makes necessary corrections in the practice management system to ensure appropriate reimbursement is receive

–         Applies a thorough understanding/interpretation of Explanation of Benefits (EOBs) and remittance advices, including when and how to ensure that correct and appropriate payment has been received.

–         Communicates effectively over the phone and through written correspondence to explain why a balance is outstanding, denied and/or underpaid using accurate and supported reasoning based on EOBs, reimbursement, and payer specific requirements.

–        Review patient medical record to compare documentation and coding; change coding based on documentation to include diagnosis codes, modifiers, place of service, etc.

–         Communicate with provider to resolve claims that require a written appeal or second level appeal. Resubmits claims with necessary information when requested through paper or electronic methods.

–         Anticipates potential areas of concern within the follow-up function; identify issues/trends and conducts staff training to address and rectify.

–        Recognizes when additional assistance is needed to resolve insurance balances and escalates appropriately and timely through defined communication and escalation channels.

–         Resolves work queues according to the prescribed priority and/or per the direction of management and in accordance with policies, procedures and other job aides.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position.


Education Requirements:

–        Bachelor or Associate degree in accounting or business-related required

–        3-5 years of medical billing experience preferred

Organizational Structure:
Job Title this position reports: Chief Financial Officer

Job Titles directly reporting to this position: None


Working Conditions: Work may be stressful at times due to continual interaction with others and the nature of the medical specialty.

Must possess the physical and mental abilities to perform the tasks normally associated with the role including bending, reaching and sitting.

Physical surroundings: Medical office

Adverse working environment Work may be stressful due to continual interaction with others, long hours required and nature of the medical specialty.

Physical Effort: Must possess the physical and mental abilities to perform the tasks normally associated with this role including prolonged sitting, walking, bending, standing, stooping and reaching. Lifting up to 15 pounds at times.

Local Travel: Occasional, within city limits only

Domestic/International Travel: None

Extensive Hours: Varies due to need

The above statements are intended to describe the general nature and level of work being performed by persons assigned to this position. They are not intended to be an exhaustive list of all associated responsibilities, skills, efforts or working conditions. Mission Cancer + Blood reserves the right to change, amend, add, delete, and otherwise assign any and all duties, responsibilities and position titles as it deems necessary to meet the needs of the business.

Mission Cancer + Blood is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based upon race, religion, color, national origin, gender, sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided on the basis of qualifications, merit, and business need.

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