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VitalConnect · 2 months ago

Denial Management Specialist

United States

Full-time

Remote

Mid Level

$22/hr - $24/hr

3+ years exp

VitalConnect is a company focused on enhancing revenue cycle management, and they are seeking a Denial Management Specialist to join their team. This role involves investigating and resolving complex insurance denials and outstanding claims to optimize reimbursement and requires collaboration with various stakeholders in the financial clearance process.

BiotechnologyHealth CareMedical DeviceWearables

Diversity & Inclusion

Responsibilities

Comprehensive research and review to resolve payer claim denials

Researches payer denials related to referral, pre-authorization, notifications, medical necessity, non-covered services, and billing resulting in denials and delays in payment

Requires extensive knowledge of carrier specific claim appeal guidelines. Conducts comprehensive reviews of the claim denial and makes determinations if an authorization needs to be obtained, a written appeal is needed, or if no action is needed

Writes and submits professionally written detailed appeals which include compelling arguments based on clinical documentation, third-party medical policies, and contract language

Customize appeals to payers in accordance with Medicare, Medicaid, and third-party guidelines as well as VitalConnect policies and procedures

Possesses proven analytical and decision-making skills to determine what selective clinical information must be submitted to properly appeal the denial

Contact payers, via website, payer portal, phone and/or correspondence, regarding reimbursement of claims

Understands medical billing requirements for Medicare, Medicaid, contracted, in-network, out of network and commercial payers

Strong understanding of insurance plans (HMO, PPO, IPO, etc.), coordination of benefits, medical terminology, limited coverage and utilization guidelines, denial remark codes and timely filing guidelines

Responsible for tracking and trending of recovery efforts by utilizing various departmental tools and appropriately reporting on-going problems specific to payers and/or contracts

Ensuring all eligible accounts are appealed within the designated payer time frames and are documented appropriately in the patient software system

Consistently meet the current productivity standards in taking appropriate actions to identify and track root causes, successfully appeal denied accounts, and trend issues

Must be cross trained and functional in all areas within the department as it relates to A/R and denials

Extensive working knowledge with insurance explanation of benefits (EOB) and comprehensive understanding of remittance and remark codes

Experience accessing payer portals such as Navinet, Availity, etc.to obtain information and upload appeals, etc

Provide individual contribution to the overall team effort of achieving the department A/R goal

Escalate exhausted accounts that will not be financially cleared as outlined by department policy to management

Contact payers to determine cause of denial and steps to appeal

Perform follow-up activities indicated by relevant management reports

Review daily payer correspondence to proactively reconcile denials in a timely manner

Maintains confidentiality of patient's financial and medical records; adheres to the State and Federal laws regulating collection in healthcare; adheres to enterprise and other regulatory confidentiality policies; and advises management of any potential compliance issues immediately

Communicate with all internal and external customers effectively and courteously

Maintain patient confidentiality, including but not limited to, compliance with HIPAA

Perform other related duties as assigned or required

Qualification

Denial managementInsurance claims processingHealthcare terminologyCPT-ICD10 codesCustomer service skillsRevenue Cycle knowledgeBasic computer proficiencyMicrosoft Suite proficiencyInterpersonal skillsWritten communicationAttention to detail

Required

A bachelor's degree or equivalent work experience is required

3+ years of experience in medical collections setting with experience in denials, appeals, insurance collections and related follow-up

Strong knowledge of healthcare terminology and CPT-ICD10 codes

Complete understanding of insurance is required

Knowledge pertaining to different insurance plans, coordination of benefits, explanation of benefits and coverage and utilization guidelines

Demonstrated customer service skills, including the ability to use appropriate judgment, independent thinking and creativity when resolving customer issues

Exceptional interpersonal skills, including the ability to establish and maintain effective relationships with patients, physicians, management, staff, and other customers

Able to communicate effectively in writing

Must be comfortable with ambiguity, exhibit good decision making and judgment capabilities, attention to detail

Must be able to maintain strict confidentiality of all personal/health sensitive information

Ability to effectively handle challenging situations and to balance multiple priorities

Basic computer proficiency inclusive of ability to access, enter and interpret computerized data/information including proficiency in Microsoft Suite applications, specifically Excel and Word

Displays a deep understanding of Revenue Cycle processes and applies knowledge to meet and maintain productivity standards as outlined by Management

Must successfully pass a background check. Due to the financial responsibilities associated with this role, the background check will be inclusive of a credit check