Specialist Technical Denial

Job Summary

The Technical Denials Specialist is responsible for analyzing, resolving, monitoring and reporting non-clinical denials to Denials Unit Manager as appropriate. The role involves follow-up and resolutions for denials escalated through a work queue, providing appropriate denial information to be submitted to departments to ensure systems, processes and measures of effectiveness (e.g. Remediation action plans) are created and implemented to resolve root cause issues and reduce/eliminate denials.

Job Description

• Reviews, researches and addresses non-clinical denials.
• Addresses all accounts assigned to work queue and completes all necessary activity as defined in departmental policies and procedures.
• Performs extensive follow-up, completes appeals and referrals to other stakeholders, when appropriate.
• Investigates and/or ensures that questions and requests for information are responded to in a timely and professional manner to ensure resolution of outstanding accounts.
• Performs ongoing monitoring of denials accounts worked, as necessary, to ensure maximization of collection dollars by providing appropriate follow-up and documenting actions taken.
• Utilizes all appropriate systems to effectively research accounts and complete steps to submit information necessary to process or appeal accounts.
• Completes follow-up with patients, as necessary, to obtain additional information.
• Prepares necessary documentation to submit appeals to payers when payment is denied.
• Makes revisions or changes to insurance information, as appropriate.
• Requests the rebilling accounts as necessary.
• Completes and/or requests adjustments to an account, as appropriate, based on adjustment thresholds.
• Reviews, works and reports (with accuracy) all accounts that have aged more than the specified grace period stipulated in the policies and/or contracts.
• Documents follow-up or patient accounts appropriately.
• Tracks and reports violation of prompt pay/adjudication terms by payers and follows up proactively with payers to provide necessary additional documentation for patient accounts that have been reviewed by payers and awaiting documentation to determine adjudication.
• Interacts with other key internal and external staff to obtain necessary information to address payment variance management issues or requests.
• Reports issues and trends to appropriate management personnel and works collaboratively to develop solutions.
• Participates in all educational activities and demonstrates personal responsibility for job performance.
• Maintains satisfactory attendance record and punctuality record as set forth by St. Elizabeth Healthcare and departmental policies.
• Consistently demonstrates a positive and professional attitude at work.
• Maintains stable performance under pressure.
• Prioritizes work/resources to accomplish objectives and meet deadlines.
• Maintains compliance with federal, state and local regulations and HIPPA.
• Maintains the privacy and security of all confidential and protected health information; job duties warrant a “high” level of computer system access (all necessary areas) to patient information ONLY for those job functions as outlined in this job description.
• Performs other duties as assigned.

Education, Credentials, Licenses

• Associates degree OR High School Diploma plus Certified Revenue Cycle Representative and 3 years of related experience.
• Demonstrates proficiency in Microsoft Office applications and others as required.
• Demonstrates knowledge and understanding of organizational policies, procedures.
• Extensive knowledge of Medicare and Medicaid regulations.
• Knowledge of insurance regulations, payment guidelines and policies and the ability to communicate and work with payors to get accounts resolved and paid accurately.