Denial Management Specialist

Job Description:

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.