Denials Management Specialist

Definition and Role

Under the direction of the Assistant Director of Revenue Cycle – Revenue Recovery, the Denial Management Specialist is responsible for monitoring denials, appeals, and resolutions from participating insurance carriers and working proactively to collect from insurance carriers.

Job Responsibilities and Duties

• Researches and analyzes denial data and coordinate denial recovery responsibilities.
• Identifies, analyzes, and researches frequent root causes of denials and develops corrective action plans for resolution of denials
• Develop reporting tools that effectively measure and monitor processes throughout the denials management process in order to support process improvement.
• Prioritizes activities to work overturns in a timely manner to alleviate untimely filings
• Uses reports that categorize denials to assign tasks or personally work to overturn denials
• Identifies and pursues opportunities for improvements in denial performance
• Assists with chart audits as necessary
• Processes work lists to facilitate prompt intervention of insurance denials
• Researches, responds, and documents insurer and patient correspondence/inquiry notes regarding coding coverage, benefits, and reimbursement on patient accounts
• Researches rejections included in EOBs for resolution and files appropriately
• Makes management aware of any issues or changes in the billing system, insurance carriers, and/or networks
• Runs daily report from the REG and compare to the PBR daily to ensure all insurance changes have been entered on both sides.
• Helps with coverage for the Financial Coordinator when she is out of the office.
• Helps when needed with retrieving mail delivered to office and sorts appropriately.

Qualifications

• Demonstrated understanding of medical terminology required
• Knowledge of patient confidentiality and HIPAA regulations
• Knowledge of CPT, HCPCS, and ICD10 coding required.
• Knowledge of medical billing and collection practices
• Understands Medicare and Medical Assistance regulations as they apply to job functions
• Knowledge working with electronic health records (EHR/EMR) or healthcare related computer systems
• Excellent written and verbal skills are required as well as outstanding interpersonal skills
• Practices efficient methods for getting work done; strong ability to prioritize workload
• Organized; sets priorities; meets deadlines
• Ability to work independently

Physical Requirements

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.

1. While performing this job the employee is frequently required to sit, talk and hear.

2. The employee is occasionally required to walk, use hands and fingers to feel, handle, or operate objects, tools or controls, and reach with hands and arms.

3. The employee must occasionally lift and/or move objects weighing up to 25 pounds.

4. Specific vision abilities required by this job include close vision and the ability to adjust and focus.

5. Emotional/Psychological: Constant ability to make decisions and concentrate.