Denials Management Specialist - 40 hrs/wk, 1st shift
Purpose of the Position
The purpose of the Denials Management Specialist is to review initial denial notifications for claims that have been partially or fully denied for reimbursement from providers. The specialist identifies the root cause of denials, responds appropriately to resolve denials, and promotes interdepartmental coordination to ensure timely and accurate reimbursement.
Job Duties/Responsibilities
Duty 1: Handles the end-to-end denial and appeal process, including analyzing, tracking, managing, and resolving denials with third-party payers.
Duty 2: Carries out appropriate research and analysis to support the appeals process and stay informed of best practices and policy changes.
Duty 3: Conducts clear, concise, and professional correspondence with payers and other stakeholders.
Duty 4: Promotes interdepartmental coordination for finding solutions and suggests improvements.
Duty 5: Examines payer remittance advice to determine the cause of reimbursement losses.
Duty 6: Accurately reviews clinical documentation to support appeals without exceeding necessary information.
Duty 7: Utilizes payer websites to research denials, submit information electronically, and follow up on appeals.
Duty 8: Posts adjustments to claim balances below the low balance threshold as per Denials Write-Off Approval Policy.
Duty 9: Relays accurate information to support A/R reduction and patient satisfaction.
Duty 10: Identifies trends in denials, determines root causes, and shares findings with the team.
Duty 11: Participates in daily huddles, idea board meetings, staff meetings, and external department meetings.
Duty 12: Communicates professionally with patients, third-party payors, provider relations, contract management, and other internal customers.
Duty 13: Identifies opportunities for system and process improvement and submits them to management.
Duty 14: Ensures services comply with state and federal regulations, organization policies, and compliance requirements.
Required Qualifications
Two (2) or more years of previous patient accounting or billing experience.
High School diploma or GED equivalent.
Understanding of CPT, ICD-10, and HCPCS coding concepts.
CPC or specialty coding certification within 12 months of date of hire.
CPFSS certification within the first 6 months of hire.
Ability to understand and interpret payer policies and navigate payer websites.
Ability to use information to develop effective appeals.
Knowledge of payer reimbursement methodologies and guidelines.
Ability to navigate provider documentation and support the appeal process.
Understanding of clean claim requirements for CMS-1500 and UB-1450 claim types.
Knowledge of remittance advice, remark codes, reason codes, and their relevance to claims.
Knowledge of revenue cycle workflows and systems such as Cerner, Trisus, Forvis, Quadax, KaiNexus, 3M, Experian, etc.
Ability to compile, analyze, and present data and complex information effectively.
Ability to educate departments within the Revenue Cycle.
Ability to manage complex issues and multiple tasks/projects.
Excellent organizational and time management skills; detail-oriented and follow-through.
Self-directed.
Strong problem-solving, research, and analytical skills.
Positive service-oriented interpersonal and communication skills.
Ability to interact with all levels of the organization, including senior leadership.
Preferred Qualifications
Denial Management experience.
College degree in a health-related field.
Payment posting experience.