Purpose:
The Denial Management Specialist role belongs to the Revenue Cycle team and is responsible for investigating and resolving complex third-party insurance denials and outstanding claims. The role aids in optimizing reimbursement by conducting exhaustive research and taking prompt action to resolve denials. The primary function of the role is to resolve payer denials while performing advanced level work related to referral, authorizations, notifications, non-coverage, medical necessity, and others as assigned. This role requires adherence to quality assurance guidelines as well as established productivity standards to support the work unit's performance expectations. This position reports to the Patient Financial Engagement Manager and requires interaction and collaboration with important stakeholders in the financial clearance process including but not limited to insurance company representatives, patients, physicians, and practice staff.
Execute the denial appeals process which includes receiving, accessing, documenting, tracking, responding to, and/or resolving appeals with third-party payers in a timely manner for services provided to managed care patients. 

Responsibilities

• Comprehensive research and review to resolve payer claim denials.
• Researches payer denials related to referral, pre-authorization, notifications, medical necessity, non-covered services, and billing resulting in denials and delays in payment.
• Requires extensive knowledge of carrier specific claim appeal guidelines. Conducts comprehensive reviews of the claim denial and makes determinations if an authorization needs to be obtained, a written appeal is needed, or if no action is needed.
• Writes and submits professionally written detailed appeals which include compelling arguments based on clinical documentation, third-party medical policies, and contract language.
• Customize appeals to payers in accordance with Medicare, Medicaid, and third-party guidelines as well as VitalConnect policies and procedures.
• Possesses proven analytical and decision-making skills to determine what selective clinical information must be submitted to properly appeal the denial.
• Contact payers, via website, payer portal, phone and/or correspondence, regarding reimbursement of claims.
• Understands medical billing requirements for Medicare, Medicaid, contracted, in-network, out of network and commercial payers.
• Strong understanding of insurance plans (HMO, PPO, IPO, etc.), coordination of benefits, medical terminology, limited coverage and utilization guidelines, denial remark codes and timely filing guidelines.
• Responsible for tracking and trending of recovery efforts by utilizing various departmental tools and appropriately reporting on-going problems specific to payers and/or contracts.
• Ensuring all eligible accounts are appealed within the designated payer time frames and are documented appropriately in the patient software system.
• Consistently meet the current productivity standards in taking appropriate actions to identify and track root causes, successfully appeal denied accounts, and trend issues.
• Must be cross trained and functional in all areas within the department as it relates to A/R and denials.
• Extensive working knowledge with insurance explanation of benefits (EOB) and comprehensive understanding of remittance and remark codes.
• Experience accessing payer portals such as Navinet, Availity, etc.to obtain information and upload appeals, etc.
• Provide individual contribution to the overall team effort of achieving the department A/R goal.
• Escalate exhausted accounts that will not be financially cleared as outlined by department policy to management.
• Contact payers to determine cause of denial and steps to appeal.
• Perform follow-up activities indicated by relevant management reports.
• Review daily payer correspondence to proactively reconcile denials in a timely manner.
• Maintains confidentiality of patient's financial and medical records; adheres to the State and Federal laws regulating collection in healthcare; adheres to enterprise and other regulatory confidentiality policies; and advises management of any potential compliance issues immediately.
• Communicate with all internal and external customers effectively and courteously.
• Maintain patient confidentiality, including but not limited to, compliance with HIPAA.
• Perform other related duties as assigned or required.

Education

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

Experience

• 3+ years of experience in medical collections setting with experience in denials, appeals, insurance collections and related follow-up.

Knowledge and Training

• Strong knowledge of healthcare terminology and CPT-ICD10 codes.
• Complete understanding of insurance is required.
• Knowledge pertaining to different insurance plans, coordination of benefits, explanation of benefits and coverage and utilization guidelines.
• Demonstrated customer service skills, including the ability to use appropriate judgment, independent thinking and creativity when resolving customer issues.
• Exceptional interpersonal skills, including the ability to establish and maintain effective relationships with patients, physicians, management, staff, and other customers.
• Able to communicate effectively in writing.
• Must be comfortable with ambiguity, exhibit good decision making and judgment capabilities, attention to detail.
• Must be able to maintain strict confidentiality of all personal/health sensitive information.
• Ability to effectively handle challenging situations and to balance multiple priorities.
• Basic computer proficiency inclusive of ability to access, enter and interpret computerized data/information including proficiency in Microsoft Suite applications, specifically Excel and Word.
• Displays a deep understanding of Revenue Cycle processes and applies knowledge to meet and maintain productivity standards as outlined by Management.

The estimated hiring salary range for this position is $22/hr to $24/hr.^* The actual salary will be based on a variety of job-related factors, including geography, skills, education and experience. The range is a good faith estimate and may be modified in the future. This role is also eligible for a range of benefits including medical, dental and 401Kretirement plan.