Denial Resolution Specialist II

About the role

Responsible for reviewing, analyzing and initiating appropriate action for complex denial resolution by communicating with payers, hospital departments and patients.

Responsibilities

• Triages denial root cause and executes appropriate next steps.
• Identifies trends and participates in interdepartmental resolution strategies to reduce and eliminate future denials.
• Researches complex denials as assigned.
• Trains staff on payer websites, providing basic guidance and instruction on website navigation.
• Uses assigned work queues and prioritization standards and guidelines to perform denial resolution follow up.
• Resolves accounts denials with high dollar balances (>$100,000) recognizing the potential complexity and the need for rapid resolution.
• Uses reference material to troubleshoot payer issues and increase understanding of denial resolution techniques.
• References payer websites as needed.
• Analyzes and researches the denial reasons for each assigned denial code.
• Recognizes and differentiates between claim denials and payment variances.
• Initiates appropriate account follow up.
• Participates in payer and internal audits.
• Supports requests for information, claim correction and/or resubmission.
• Maintains appropriate documentation related to original audit findings.
• Corrects and updates claim information in the Medicare FISS system requiring in depth knowledge of Medicare billing and compliance regulations.
• Correct and resubmit claims in Mass Health MMIS and other payer websites.
• Completes appropriate actions needed for an effective appeal including conducting authorization research, rebilling, and balance write off or transfer to next responsible party.
• Escalates issues as appropriate.
• Corresponds with third party payers, hospital departments, and patients to obtain information required for denial resolution following payer timelines.
• Releases information following Federal, State and Hospital guidelines.
• Follows payers established procedures and timelines to submit appeals utilizing payers preferred method, i.e., electronically or via paper.
• Documents all actions taken during the denial resolution process clearly including actions taken, next steps, payer processing timelines, etc.
• Adjusts account balances using correct transaction while code adhering to guidelines.
• Follows established protocols to ensure all documents are retained appropriately.
• Meets established quality and productivity standards.
• Facilitates and promotes the sharing of knowledge and content throughout departments.
• Follows all established Hospital Billing Revenue Cycle Management departmental and compliance policies and procedures.
• Adheres to change control processes.
• Participates in cross training to optimize resources.
• Demonstrates excellent attendance and actively participates in a variety of meetings and training sessions as required.
• Maintains and fosters an organized, clean, and safe work environment.
• Actively contributes to the development and application of process improvements.
• Maintains a collaborative, team relationship with peers and colleagues in order to effectively contribute to the group’s achievement of goals and to help foster a positive work environment.
• Demonstrates respect for the diversity of patient and employee populations.
• Supports and encourages diverse points of view, work, and lifestyles.
• Practices cost containment and fiscal responsibility through the efficient use of supplies, equipment, time, etc.
• Performs a variety of related duties as assigned by management.

Qualifications

• Required: A minimum of a High School diploma.
• Required: Four or more years of experience in health care billing functions.
• Required: Previous health care billing experience.
• Required: Proven track record of successful performance and goal achievement.
• Required: Experience in denial resolution process.
• Required: Advanced knowledge of claim form content and claim submission requirements.
• Required: Understands and can explain the purpose of revenue codes, condition codes, occurrence codes, modifiers and value codes.
• Required: Proactively proposes resolutions to issues.
• Required: Ability to communicate verbally and clearly document all actions taken during resolution process.
• Required: Demonstrates ability to research denial issues.
• Required: Can provide root cause of denial issue and identify next steps needed to resolve issue.
• Required: Ability to navigate in MassHealth claims processing application and/or the Medicare claims processing application.
• Required: Experience with high dollar- high complexity claim submissions, i.e. Long length of stay, coverage changes and lapse, coordination of benefit issues.
• Required: Ability to work collaboratively and effectively with people.
• Required: Exceptional communication and interpersonal skills.

Schedule

• Monday through Friday
• Scheduled Hours: 8:00 AM – 4:00 PM
• Shift: Day Shift, 8 Hours
• Hours: 40

Pay

• Hiring Range: $20.94 – $29.27 per hour
• Final offer may vary within this range based on a candidate’s experience, skills, qualifications, and internal equity considerations.

Benefits

• This position may have a signing bonus available; a member of the Recruitment Team will confirm eligibility during the interview process.

Union

SHARE (State Healthcare and Research Employees)