The Denials Specialist performs advanced-level work related to clinical and coding denial management and appeals follow-up. The individual is responsible for conducting a comprehensive review of the insurance denial and working with the Clinical Denials Nurses and Coding Denials Specialists to compile appropriate documentation and medical records to submit appeals or corrected claims in a timely manner. This position applies prior knowledge of denials to assess and ensure services/items billed are reasonable and necessary, supported by national/local coverage determinations and commercial medical policies. Additionally, this position will actively manage, maintain and communicate denial / appeal activity to appropriate stakeholders and report suspected or emerging trends related to payer denials to Leadership. This position anticipates and responds to a wide variety of issues/concerns. The Denials Specialist works independently to plan, schedule and organize activities that directly impact hospital and physician reimbursement. This role is key to securing reimbursement and minimizing organizational write offs.
Responsibilities/Job Description:
- Formulates strategy for prioritizing cases and maintains aging within appropriate ranges with minimal direction or intervention from Leadership.
- Reviews account history, remit, payer history, and state requirements to determine appropriate challenge and appeal strategy.
- Gathers and fill out all special appeal or payer required forms.
- Composes and submits all required documentation (including appropriate medical records to support medical necessity) for a reconsideration, appeal, or retro authorization to the insurance carrier via payer portal, fax, etc…
- Documents and summarizes all rationale for all appeals in EPIC. Documents communications with medical office staff and/or MD provider as required.
- Follows up on submitted appeals through payer portal or phone calls to the payer.
- Escalates issues in accordance with the department escalation policy. Uses critical thinking skills to resolve aged and problematic accounts.
- Follows account to timely resolution to include appropriate financial adjustment.
- Interfaces with other departments to satisfactorily resolve issues related to appeals and initial denials.
- Communicates with Pre-Cert team and/or medical office personnel to obtain pertinent information.
- Maintains a thorough understanding of operations and business unit processes/workflows including, but not limited to authorizations and referral requirements, and in/out-of-network insurances.
- Maintains payer portal access and utilizes said portals to assist in reviewing commercial medical policies or LCD and NCD (local and national coverage determination) rules. Maintains a current knowledge of CMS rules and regulations relating to the grievance and appeal processes.
- Maintains working knowledge of applicable insurance carriers’ timely filing deadlines, claims submission processes, and appeal processes and escalates timely filing requests to Leadership.
- Collaborates with Clinical Denials Nurse, Coding Denials Specialists, and Leadership in high-dollar claim denial review.
- Monitors for denial trends, works collaboratively with the revenue cycle teams to reduce revenue loss. Helps identify issues from denials and appeals that might be avoided on future claims.
- Assist department leadership with research, analysis and special projects. Attends necessary payer meetings to escalate denials issues.
- Participate in huddle meetings and sharing the details of cases worked
Qualifications:
Required - Two years' recent experience in healthcare revenue cycle or prior authorizations for inpatient/outpatient, hospital/physician
- Experience in healthcare claims processing and proficiency with medical billing and remittance forms and processes, including 835 and 837 files, and UB04 and CMS-1500 (HCFA) forms
- Experience in managing and appealing authorization or medical necessity denials
- Medical terminology
