Insurance Denial Specialist

Insurance Denial Specialist

Position Summary

The Denial Specialist will be responsible for coordinating appeals and collection efforts for denied / underpaid services performed at St. Joseph’s / Candler and its affiliates where applicable. The scope of work will encompass all Government, Commercial and Managed Care payers, and include all service lines and all denial types. Position will be a liaison with other departments, physicians and other clinicians within and outside the organization in order to facilitate timely and accurate submission and processing of appeals. The Denial Specialist will work closely with management, precertificiation, insurance verification, and operations to ensure trends are identified and corrected to reduce denials.

Education

Associates - Preferred

Experience

2-3 Years medical background - Preferred

1-2 Years insurance, oncology billing and / or denial management experience - Preferred

License & Certification

None Required

Core Job Functions

• Demonstrates responsibility in maintaining patient records in organized and secure manner. Ensures HIPAA regulations are continuously followed.
• Meets monthly departmental goals for recovery of denials / underpayments. Reports denial / underpayment specifics and identifies trends. Improves methods for tracking, monitoring and appealing claim denials / underpayments.
• Reviews monthly denials with leadership team of the physician's office, ancillary departments and revenue cycle. Identifies improvement opportunities, educational needs and reduction of denials opportunities.
• Escalates payer denial trends or underpayments to appropriate internal leadership for quick resolution.
• Gathers and reviews documentation via Medical Record and other peripheral documentation from outside physicians and clinicians. Writes formal Reconsideration and Appeal Letters based on circumstances surrounding the denial and / or the patient’s clinical indications. Complies and submits required documentation for appeal. Follows up with payer provider representative for contract issues and claim disputes. Facilitates peer-to-peer reviews. Ensures appeals are completed and filed per payer time limits. Documents all actions taken in appropriate computer systems.

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