DENIAL MANAGEMENT SPECIALIST

The Denial Management Specialist at the entry or intermediate level is responsible for reviewing and resolving denied or underpaid medical claims, ensuring the timely follow-up of outstanding issues, and assisting in the development of strategies to reduce future denials. The role involves working closely with the billing and coding teams to correct claims and maintain compliance with payer regulations. The specialist will also use analytical tools to assist with identifying denial patterns and contribute to process improvements.

•  Health Insurance/HMO 
•  Enjoy unlimited MadMax Coffee
•  Diverse learning & growth opportunities
•  Accessible Cloud HR platform (Sprout)
•  Above standard leaves

Claims Review and Resolution

• Review and analyze denied or underpaid medical claims to determine the reason for the denial.

• Take appropriate actions to appeal denied claims by submitting necessary documentation or corrections.

• Communicate with insurance companies and payers to resolve outstanding claims issues.

• Ensure timely follow-up on all unresolved claims to facilitate prompt payment.

Documentation and Coding Assistance

• Work with coding and billing teams to ensure claims are accurately coded and submitted according to payer guidelines.

• Identify common coding or documentation errors that lead to denials and collaborate with teams to address them.

• Assist in gathering supporting documentation for claims appeals and resubmissions.

Tracking and Reporting

• Maintain accurate records of denied claims, appeals, and resolutions using denial management software or electronic health record (EHR) systems.

• Prepare basic reports on denial trends for internal review, assisting in identifying common issues and opportunities for improvement.

• Track performance metrics such as denial rates, appeal success rates, and resolution times.

Process Improvement Support

• Assist in identifying potential improvements in denial management workflows and contribute ideas for more efficient processes.

• Support the implementation of process improvement initiatives aimed at reducing denial rates.

• Participate in training sessions related to coding, billing, and denial management to stay updated on changes in payer regulations and industry best practices.

Compliance and Policy Adherence

• Ensure all denial management activities comply with federal, state, and payer regulations.

• Stay informed of payer policies and requirements to ensure accurate claims submissions.

• Follow internal guidelines and protocols for managing denied claims and appeals.

Collaboration and Communication

• Communicate effectively with internal departments such as coding, billing, and compliance teams to resolve claims issues.

• Respond to inquiries from insurance companies, patients, and internal staff regarding claim statuses and denial reasons.

• Escalate complex or unresolved denial issues to senior specialists or management for further review.

• At least 2 years of experience in Revenue Cycle Management (RCM).

Additional relevant knowledge or experience related to the above requirements will be considered an advantage.