Denials Specialist - Remote

Denials Specialist

*100% remote, must live in one of the states listed below*

(FL,TN,RI,NJ,ME,GA,MS)

Our Culture: Why work with us?

Joining Outer Cape Health Services isn't just about taking on a new role; it's about embracing a mission that goes beyond the day-to-day. Here, you become part of a dedicated team committed to safeguarding and nurturing invaluable community health resources. Our ethos is built on creating a vibrant and inclusive workplace where every team member is valued and recognized for their unique contributions.

Who We Are :

Our mission is to provide a full range of primary health care and supportive social services that promote the health and well-being of all who live in or visit the ten outermost towns of Cape Cod.

OCHS now cares for more than 18,000 patients annually, and no one is denied access to services due to an inability to pay. Founded in 1987 through the merger of Health Associates of Provincetown (established in 1972) and the AIM Medical Center in Wellfleet (established in 1966), Outer Cape Health has a long history of successful growth and expansion in pursuit of this mission. As a Patient-Centered Medical Home, OCHS holds itself to the highest standards. Ensuring patients have access to care when they need it and request it, and validating that staff are working at the top of their licensures, are foundations of this model.

Our Core Competencies:

At Outer Cape Health Services, our core competencies are the foundation upon which our organization is built, guiding us in our mission to deliver exceptional health services to our communities. Our focus on fostering teamwork ensures that we operate as a cohesive unit, valuing each member's contribution and working synergistically towards common goals. Integrity and honesty stand at the heart of everything we do, creating a culture of trust and respect among our team and the communities we serve. Embracing technology, we continually seek innovative solutions to enhance our services and operations. Finally, being patient-centered, we prioritize the needs and well-being of those we serve, striving to exceed expectations and make a meaningful difference in their lives.

A day in the life of this role:

At Outer Cape Health Services, it is our belief that it is people who have made OCHS' growth and success possible and that we have been fortunate in employing people who take pride in the services we provide. Our goal at OCHS is to employ those who (1) always meet or exceed standards; and (2) care enough to ensure that whatever they do, they do well.

The Denials Specialist will be responsible for reviewing, correcting, trending, and resolving provider enrollment denials.

Summary of duties:

• Review pre-bill holds relating to provider enrollment issues.
• Review, correct, track, trend, and quantify back-end denials for provider enrollments.
• Escalate trends identified to Senior Enrollment Analyst for corrections.
• Quantify and report provider enrollment adjustments needed to be posted due to a delay in onboarding the provider.
• Monitor aging reports for timely follow-up on all unpaid denied claims.
• Assist the review of corrections for denials related to registration, demographic, and any other pertinent information used to assist in claim resolution.
• Attend monthly Insurance payer calls as a resource to escalate provider enrollment and back-end denials.
• Works with payers on submitting projects in bulk as needed.
• Post patient payments as needed.
• Review and resolve issues for denied claims, including review of payer and clearinghouse responses.
• Prepare secondary and tertiary claims for electronic submission.
• Adjust claim balances based on billing policies and appropriate payer responses.
• Prepare payer refunds for electronic submission.
• Eligibility verification for patient coverage requirements.
• Set patient payment plans according to policy.
• Closes all payment batches in the computer system daily.
• Enters refund requests into EPIC and forwards to the appropriate individual for issuance of refunds.
• Assigns accounts to appropriate claim status and notes accounts.
• Reviews insurance companies' incorrect reimbursements and report all findings to Revenue Cycle Director.

What we need from you:

• Excellent verbal and written communication skills.
• Knowledge of and experience with electronic medical records.
• At least 2 years prior experience in revenue cycle.
• High school degree required.
• Possess strong analytical skills and computer skills including Outlook, Excel, and Word
• Customer / Patient Account Services Skills.
• Prefer knowledge of Provider Enrollment denials.
• Strong knowledge of third-party payors guidelines and policies required.
• Health care claims processing and follow-up background.
• Billing experience and insurance knowledge (eligibility, registration, etc.)
• Prior experience with EPIC billing system is strongly preferred but not required.
• Results oriented while balancing multiple priorities and tasks.
• Possess strong analytical skills and computer skills including Outlook, Excel, and Word.

AAP/EEO Statement Outer Cape Health Services is committed to a firm policy in favor of equal employment opportunity and will abide by all applicable state and federal regulations by not discriminating against any applicant or employee on the basis of race, religion, color, creed, sex, age, national origin, citizenship status, marital status, sexual orientation, gender identity and expression, disability or veteran status. Our commitment to equal employment opportunities shall include employment, upgrading, promotion, demotion, transfer, leaves or other absences from work, layoff, compensation and benefits, selection for training or other education, professional opportunities and conflict resolution.

It is also the policy of OCHS to take affirmative action to employ and to advance in employment, all persons regardless of their status as woman, minority or individuals with disabilities or protected veterans, and to base all employment decisions only on valid job requirements.

Please inform us of any necessary accommodations required during the application process and/or at any time during employment.