Denials Resolution Specialist

Key Responsibilities

• Conducts root cause analysis of all assigned insurance payer claims and denials to determine appropriate actions required to resolve the claim / denial into a paid status.
• 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.
• Buils relationships with MCO.
• Corrects identified billing errors and resubmits claims with necessary information through paper or electronic methods.
• Anticipates potential areas of concern within the claim’s denial function; identify issues/trends and provides feedback to Manager / Corporate Director Revenue Cycle.
• Recognizes when additional assistance is needed to resolve claim denials and escalates appropriately and timely through defined communication and escalation channels.
• Carry out insurance appeals
• Resolves work assigned according to the prescribed priority and/or per the direction of the Manager and in accordance with policies, procedures and other job aides.
• Assists with unusual, complex or escalated issues as necessary.
• Organizes open accounts by denial type or payer to quickly address in bulk with representatives over the phone, via spreadsheet, utilizing an on-line payer portal, etc.
• Documents all activities and findings in accordance with established policies and procedures; ensures the integrity of all account documentation; maintains confidentiality of medical records.
• Identifies potential trends in denials/reimbursement by payer or by type, denial reason, or coding issue and reports to supervisory staff for appropriate escalation.
• Uses critical thinking skills and payer knowledge to recommend system edits to reduce denials and result in prompt and accurate payment.
• Keeps management informed of changes in billing requirements and rejection or denial codes as they pertain to claim processing and coding.
• Communicates with Manager and staff regarding insurance carrier contractual and regulatory requirements that impact payment and denials.
• Maintains quality assurance and productivity standards for timely and accurate claim / denial resolution in accordance with organizational policies and procedures.
• Maintains current knowledge of internal, industry, and government regulations as applicable to assigned function. Understands detailed billing requirements, denial reason codes, and insurance follow-up practices.
• Understands government and commercial insurance reimbursement terms, contract language, and appropriate reimbursement amounts.
• Has knowledge of, and is compliant with, government regulations including "signature on file" requirements, compliance program, HIPAA, etc.

Key Experience and Education Needed

• High school graduate or equivalent is required
• Some college coursework is preferred
• Graduate from a post-high school certificate program in medical billing or another business-related field is preferred

KNOWLEDGE/SKILLS/ABILITIES

• Two years claim review and/or denial resolution experience which demonstrates attainment of the required requisite job knowledge and abilities.
• Knowledge of medical insurance, payer contracts, and basic medical terminology and abbreviations
• Ability to effectively prioritize and execute tasks while under pressure; make decisions based on available information and within the scope of authority of the position; excellent customer service skills, including professional telephone interactions.
• Effective organizational and problem-solving skills are required
• Demonstrated ability with medical billing systems and third-party payment processes are required.
• Good verbal and written business communication skills sufficient to clearly document issues and effectively communicate.
• Detail oriented
• Excellent keyboarding skills and experience with medical billing systems.
• Substance abuse experience preferred.
• Ability to maintain confidentiality and handle crisis situations in a calm and supportive manner
• Ability to exhibit professional and courteous behavior, consistent with the ARC mission statement, when interacting with persons of varying backgrounds and education levels to create a safe and healthy relationship with clients served
• Flexibility to adapt to schedule changes and assumption of responsibilities not delineated in the job description which are related to work as a member of an addiction treatment team.

Benefits

Addiction Recovery Care, LLC and its affiliated entities are an equal opportunity employer.

ADA Disclaimer: In developing this job description care was taken to include all competencies needed to successfully perform in this position. However, for Americans with Disabilities Act (ADA) purposes, the essential functions of the job may or may not have been described for purposes of ADA reasonable accommodation. All reasonable accommodation requests will be reviewed and evaluated on a case-by-case basis.