Denial Management Specialist

This is a fully remote position, open to applicants in California.

📋 Description

• Conduct thorough research and analysis to address payer claim denials.

• Investigate payer denials pertaining to referrals, pre-authorizations, notifications, medical necessity, non-covered services, and billing issues that lead to denials and payment delays.

• Requires in-depth knowledge of specific carrier claim appeal guidelines.

• Performs detailed reviews of claim denials to determine if an authorization is required, if a formal appeal is necessary, or if no action is needed.

• Crafts and submits well-structured and detailed appeals that present compelling arguments based on clinical documentation, third-party medical policies, and contractual language.

• Tailors appeals to payers in alignment with Medicare, Medicaid, and third-party guidelines, as well as VitalConnect's policies and procedures.

• Demonstrates strong analytical and decision-making abilities to identify which clinical information should be submitted to effectively appeal a denial.

• Communicates with payers through various channels, including websites, payer portals, phone calls, and correspondence, regarding claims reimbursement.

• Possesses a solid understanding of medical billing requirements for Medicare, Medicaid, contracted, in-network, out-of-network, and commercial payers.

• Has a strong grasp of insurance plans (HMO, PPO, IPO, etc.), coordination of benefits, medical terminology, limited coverage and utilization guidelines, denial remark codes, and timely filing rules.

• Responsible for monitoring and analyzing recovery efforts using various departmental tools while accurately reporting ongoing issues specific to payers and/or contracts.

• Ensures that all eligible accounts are appealed within the specified timeframes set by payers and are documented correctly in the patient software system.

• Consistently meets current productivity standards by taking appropriate steps to identify and track root causes, successfully appeal denied accounts, and analyze trends.

• Must be cross-trained and proficient in all areas within the department related to accounts receivable and denials.

• Possesses extensive knowledge of insurance explanations of benefits (EOB) and a thorough understanding of remittance and remark codes.

• Experienced in accessing payer portals such as Navinet and Availity to gather information and upload appeals.

• Contributes individually to the overall team effort in achieving the department's A/R goals.

• Escalates unresolved accounts that cannot be financially cleared as per department policy to management.

• Engages with payers to ascertain the reasons for denials and the steps required for appealing.

• Performs follow-up tasks as indicated by relevant management reports.

• Reviews daily correspondence from payers to proactively address denials in a timely manner.

• Maintains the confidentiality of patients' financial and medical records; complies with state and federal laws governing healthcare collection practices; adheres to enterprise and other regulatory confidentiality policies; and promptly informs management of any potential compliance issues.

• Effectively and courteously communicates with all internal and external customers.

• Upholds patient confidentiality, including compliance with HIPAA regulations.

• Undertakes other related duties as assigned or required.

⛳️ Requirements

• A bachelor’s degree or equivalent work experience is mandatory.

• A minimum of 3 years of experience in a medical collections environment, with a focus on denials, appeals, insurance collections, and follow-up activities.

• Strong knowledge of healthcare terminology and CPT-ICD10 codes is essential.

• A comprehensive understanding of insurance is required.

• Familiarity with various insurance plans, coordination of benefits, explanations of benefits, and coverage and utilization guidelines is important.

• Proven customer service skills, including the ability to exercise sound judgment, independent thinking, and creativity when addressing customer concerns.

• Outstanding interpersonal skills, enabling effective and lasting relationships with patients, physicians, management, staff, and other stakeholders.

• Capable of effective written communication.

• Must be comfortable with ambiguity, demonstrating good decision-making and judgment skills, along with attention to detail.

• Must maintain strict confidentiality regarding all personal and health-sensitive information.

• Ability to manage challenging situations while balancing multiple priorities.

• Basic computer proficiency, including the capability to access, enter, and interpret computerized data/information, with proficiency in Microsoft Suite applications, particularly Excel and Word.

• Exhibits a thorough understanding of Revenue Cycle processes and applies this knowledge to meet and sustain productivity standards as set by management.

🏝️ Benefits

• Medical insurance

• Dental coverage

• 401K retirement plan