Denial Management Specialist

SUMMARY

The Denial Management Specialist will report directly to the Payor Relations & Customer Experience (PRCE) Manager, while working closely with Customer Experience Specialists (CEx) and Triage and Order Quality (TOQ) personnel to support financial objectives through strategic and tactical activities, actively engaging with payors, providers, and patients, resulting in the highest-level reimbursement on submitted claims.

The Denial Management Specialist is responsible for the optimal payment of claims from Medicare, Medicaid, BCBS, Contracted, Commercial and Manage Care Plans. Primary duties include but are not limited to: consistent follow up on unpaid, underpaid & denied claims, filing appeals when appropriate to obtain maximum reimbursement, establish and maintain strong relationships with providers, clients and fellow staff, and monitor trend in denials of payment changes.

• Investigates insurance denials and identifies and implements best recommended action and coordinates with other departments/stakeholders as needed.
• Solves billing questions/problems and audits patient accounts.
• Understands and adheres to each insurance carrier's reconsideration and appeal submission guidelines.
• Makes necessary adjustments to patient balances based on Explanation of Benefits (EOB)
• Determines need for payer appeal and sends individual appeal letters. Monitors appeal for resolution.
• Conducts insurance negotiation for non-par payments and escalates to the PRCE Manager as needed.
• Excellent customer service skills - communicates effectively with patients to retrieve required consent forms and providers to retrieve required records.
• Reviews and analyzes insurance claims with accounts receivable balances that are aged beyond 30 days old
• Access denied claims from RPM system work queue and queries claim status with the payor, utilizing all appropriate systems, websites to effectively research the claim and resubmit or appeal as necessary.
• Makes necessary arrangements for medical records requests, completion of additional information requests etc. as requested by insurance companies to ensure timely resolution of outstanding denied/unpaid claims.
• Prioritize claims based on ageing and outstanding dollar amounts, or as directed by management.
• Regularly meets with PRCE Manager to discuss challenges or billing obstacles as well as to provide status of outstanding ageing reports worked.
• Follow all compliance and HIPAA standard when documenting accounts and communicating with patients.
• Ability to handle multiple projects at the same time but remain organized - strong sense of urgency for schedules.
• Uphold company mission and values through accountability, innovation, integrity, quality, and teamwork.
• Regular and reliable attendance.

MINIMUM QUALIFICATIONS

• High School Degree/General Education Degree and 4 years of relevant experience in Customer Service, medical industry or relevant experience as outlined in the essential duties in lieu of bachelor's degree.
• 4+ years of experience in customer service and appeals.
• Demonstrated ability to think critically and apply customer lens judgement in actioning and resolving inquiries.
• Strong understanding of customer service, medical billing, insurance, and data entry.
• Advanced proficiency in customer service systems, CRMS, Phone systems, Billing Platforms.
• Fluency in English required. Spanish / Bilingual a plus
• Proficiency in Microsoft Office, to include Word, Excel, Outlook, SharePoint.
• Demonstrated ability to perform the Essential Duties of the position with or without accommodation.
• Maturity and good judgment to understand when to exercise initiative and handle queries directly, and when to escalate queries to higher authority.
• An excellent team player - highly effective at working with others and capable of working independently most of the time.
• Ability to multi-task and attention to detail. Must be able to work in a fast paced, time-sensitive environment.
• A deep understanding of insurance denials drivers and an overt willingness to be an internal champion for both the patient and health care providers.
• Must have superior interpersonal and organizational skills. Excellent listening, oral and written communication skills. A high level of empathy, enthusiasm, and self-confidence.
• Professional telephone manner.

Preferred Qualifications

• Clinical / Medical or other ancillary service type background.
• Minimum of 4 years appeal experience in Health Care, Lab, DME Pharmaceutical industry preferred.
• Bachelor's Degree preferred.
• Significant PC knowledge & Windows OS experience. Skilled competence with Five9, XiFin, Microsoft Office, Salesforce.com a plus.

EDUCATION and/or EXPERIENCE

Position generally requires a High school diploma or general education degree (GED) and two years of related experience in medical appeals. Should be familiar with accessing Medical Coding (CPT & Diagnostic Codes) and HIPPA rules and regulations. Should understand medical terminology, EOB's and CMS 1500's and insurance classifications such as HMO, PPO, Medicare and private insurances. Familiarity with insurance plans, third party administrators, and governmental rules and regulations preferred. Candidates must be able to work with a high volume of work while maintaining attention to detail and accuracy and demonstrate excellent oral and written communication skills. Computer skills required to operate practice management system (i.e., use Window operating system, conduct Internet searches, communicate by email, etc.)

LANGUAGE SKILLS

Must be fluent in both verbal and written English. Must have the ability to speak effectively to provide information and respond to questions from managers, employees, patients, and payor representatives. Must have the ability to read and comprehend simple instructions, correspondence, and memos. Ability to prepare routine appeals and effectively communicate electronically and via telephone. Ability to respond to patients in an empathetic and professional manner. Ability to effectively present information in one-on-one and small group situations with other employees of the organization.

MATHEMATICAL SKILLS

Ability to add and subtract numbers, to multiply and divide with 10's and 100's and to compute percents and fractions. Ability to perform these operations using units of American currency.

REASONING ABILITY

Ability to recognize problems, collect relative data, establish facts, draw valid conclusions and take appropriate action under close supervision. Ability to understand and appreciate HIPPA rules and regulations regarding patient privacy.

CERTIFICATES, LICENSES, REGISTRATIONS

None required.

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 accommodation may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit for extended periods of time in front of a computer monitor. The employee is required to use headphones for extended periods of time while handling phone calls. The employee is required to perform extensive data entry. The employee frequently is required to use hands to finger, handle, or feel and talk or hear. The employee is occasionally required to stand, walk, and reach with hands and arms. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision and ability to adjust focus.

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually quiet.

All qualified applicants are considered for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability, veteran status or other protected class.