Denials Specialist

JOB SUMMARY

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

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Validate denial reasons and ensures coding is accurate with HIM department and reflects the denial reasons. Coordinate with the Case Management department for clinical consultations or account referrals, when necessary,
• Generate an appeal based on the dispute reason and contract terms specific to the payor. This includes 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 adjudication issues, and referral to refund unit on overpayments.
• Perform research and makes determination of corrective actions and takes appropriate steps to note the EMR system and route account appropriately.
• Escalate denial or payment variance trends to manager and/or director for payor escalation.
• Others as assigned

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• 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-10, HCPCS/CPT coding and medical terminology
• Intermediate Microsoft Office (Word, Excel) skills
• Advanced business letter writing skills to include correct use of grammar and punctuation.

EDUCATION / EXPERIENCE

Minimum education, technical training, and/or experience preferred to perform the job.

• Associate’s degree and/or some college coursework or considerable work experience preferred.
• 3 - 5 years experience in a hospital business environment performing billing, collections, coding and/or insurance appeals.

PHYSICAL DEMANDS

• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Ability to sit and work at a computer terminal for extended periods of time.

WORK ENVIRONMENT

• Multiple workstations in close proximity