Denials Specialist - Remote

About the role

Responsible for validating dispute reasons following Explanation of Benefits (EOB) review, escalating payment variance trends or issues to NIC management, and generating appeals for denied or underpaid claims.

Responsibilities

• Validate denial reasons and ensure coding in DCM is accurate and reflects the denial reasons.
• Coordinate with the Clinical Resource Center (CRC) for clinical consultations or account referrals when necessary.
• Generate an appeal based on the dispute reason and contract terms specific to the payor, including online reconsiderations.
• Follow specific payer guidelines for appeals submission.
• Escalate exhausted appeal efforts for resolution.
• Work payer projects as directed.
• Research contract terms/interpretation and compile necessary supporting documentation for appeals, Terms & Conditions for Internet enabled Managed Care System (IMaCS) adjudication issues, and referral to refund unit on overpayments.
• Perform research and determine corrective actions, take appropriate steps to code the DCM system and route the account appropriately.
• Escalate denial or payment variance trends to NIC leadership team for payor escalation.

Requirements

• Intermediate understanding of Explanation of Benefits form (EOB), Managed Care Contracts, Contract Language and Federal and State Requirements.
• Intermediate knowledge of hospital billing form requirements (UB-04).
• Intermediate understanding of ICD-9, HCPCS/CPT coding and medical terminology.
• Intermediate Microsoft Office (Word, Excel) skills.
• Advanced business letter writing skills, including correct use of grammar and punctuation.
• Ability to obtain and provide confirmation of required vaccinations and screenings prior to start of employment (e.g., COVID-19, influenza, future vaccines).

Education / Experience

• High School Diploma or equivalent; some college coursework preferred.
• 3‑5 years experience in a hospital business environment performing billing and/or collections.

Benefits

• Medical, dental, vision, disability, and life insurance.
• Paid time off (vacation & sick leave) – minimum of 12 days per year, accruing at approximately 1.84 hours per 40 hours worked.
• 401(k) with up to 6% employer match.
• 10 paid holidays per year.
• Health savings accounts, healthcare & dependent flexible spending accounts.
• Employee Assistance program, Employee discount program.
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, AD&D, auto & home insurance.
• For Colorado employees, paid leave in accordance with Colorado’s Healthy Families and Workplaces Act.

Pay

$18.60 - $28.00 per hour. Compensation depends on location, qualifications, and experience. Position may be eligible for a signing bonus for qualified new hires, subject to employment status. Conifer observed holidays receive time and a half.