The Denials Management Representative reports to the Insurance Follow-Up and Denials Manager and will be responsible for the following:
Reviewing accounts which have been denied or underpaid by third party payors and resolving issues resulting in denial/underpayment.
Conducting comprehensive reviews of clinical documentation to determine if appeals are warranted.
Working across several departments to gather the appropriate documentation and information for a clear and concise appeal.
Drafting and sending out appeals for both clinical and non-clinical denials, especially in situations where the particular denial reason could prove financial fatal.
Creating and navigating the Denials Management Desktop in Meditech environments, including 6.0.8, 6.1.6, and any other updates in the future.
Performing consistent follow-up on pending denial appeals as well as placing appropriate statuses on current open accounts for future timely follow-up activities.
Abide by business office productivity standards which are set by business office leadership and are subject to change based on industry expectations.
Reading and understanding patient medical records and ensuring HIPAA confidentiality laws are met and maintained within the organization.
Other duties as assigned - Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee partner for this job. Duties, responsibilities and activities may change at any time with or without notice.
Must meet one of the following:
High school diploma, required.
Associate degree or Bachelor of Arts or Science degree, preferred.
Detailed knowledge of third party payor regulations related to managed care, denials, and reimbursement issues; terminology for hospital billing; and CPT and ICD-10 coding.
Demonstrated ability to exhibit exemplary core customer skills at all times.
At least two (2) or more years of experience and/or knowledge with the following:
Successfully handling the rigors associated with employment in the following fields: patient financial services, patient customer service, clinical appeals, and hospital billing/coding.
Researching and resolving insurance payment discrepancies.
Identifying, analyzing, and researching frequent root causes of denials and developing corrective action plans for denial resolution.
Communicating effectively via phone with carriers, physician staff, and management to make aware of any issues or changes in the billing system, insurance providers, and/or networks.
Certified Revenue Cycle Representative (CRCR), preferred.
Independent decision-making skills, collaborative abilities, organized, and time management skills.
May be asked to work evenings, as needed.
Physical Requirements: Light Physical Agility Test (PAT) Rating
While performing the duties of this job, the employee is frequently (activity or condition exists from 1/3 to 2/3 of the time) required to stand, sit, and walk; frequently to use hands, fingers; and frequently to talk or hear. The employee must exert up to 15 pounds of force occasionally (activity or condition exists up to 1/3 of the time), and/or up to 5 pounds of force frequently, and/or a negligible amount of force constantly to move objects.
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.
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Full Time, Non-Exempt