Denial Management Specialist

Position Summary:   Ensures optimal performance in all areas of denial prevention and appeal processing. Responsible for monitoring state and federal regulatory agencies and payer information to maintain up-to-date knowledge on changing rules and regulations affecting Medical and Dental practice reimbursement. Correct and resubmit claims to reduce reimbursement delays. Assist management with assigned special projects which may include provider and staff training & education.

Job Duties:

The following are essential job accountabilities:

  1. Follow up on denied claims from all commercial and contracted payers where denials can be associated with coding errors. Assign and sequence ICD-10-CM/CPT-4 diagnostic and procedural codes review physician documentation & coding for appropriateness & accuracy make corrections following Medicare & AMA coding guidelines.
  2. Review and analyze medical records for accurate ICD & CPT selection and serve as the coding subject matter expert for the patient accounts denial management function.
  3. The denial management specialist thoroughly investigates denied claims to ensure timely and proper follow-up for addressing denials including assigning them to appropriate OMNI providers as well as coordinating with the insurance claims representative and OMNI collection specialists/charge posters to complete the research to support the claim review and to determine and execute the appropriate course of action for resubmission of the claims to obtain reimbursement in a timely manner.
  4. Perform timely and appropriate validation and follow up on denied claims, including initial assessment of the denials received via DSG EDI
  5. Identify and escalate coding trends that are impacting denial volume.
  6. Perform retrospective audits of new self pay accounts to update demographic information.
  7. Resolves routine coding issues/problems and initiates additional training as needed with staff and providers. 

Additional Duties

  1. HIPAA compliance – Responsible for enforcing compliance with all HIPAA regulations and requirements. Treats all member information confidential.
  2. Compliance – Ensure compliance with all local, state, and federal regulations.
  3. QA/QI – Participate in QA/QI activities and contribute towards the overall performance improvement of the organization.
  4. IT – Required to learn and use the Electronic Health Record and Practice Electronic System and its components as required by the job functions and highlighted in the Policies and Procedures.
  5. All employees will participate in Patient Centered Home Health Model at Omni Family Health.

Qualifications, Education, and Experience

Education:

  1. High school diploma or GED

Experience:

  1. Minimum of two years billing and accounts receivable experience in a physician practice with two in an FQHC environment.
  1. Minimum of three years physician coding experience in a multi-specialty environment.

Certifications:

  1. CPC, CPCH, and/or CCS-P certification required
  1. Maintain annual coding certification requirements

Skills:

  1. Must have working knowledge of coding rules, and third party payer requirements

Responsible to:           Director of Billing

Classification:             Full-time , Non-exempt