FT; Mon-Fri 8:00am - 5:00 pm
We re searching for a Claims Denial & Appeal Specialist, responsible for reviewing and analyzing claim denials, working with payors to resolve denials, tracking all denials by payor and denial category, trending recurring denials, and recommending process improvement or system edits to eliminate future denials. Reviews monthly report for Denials Management Leadership Team and serves as a member of this team to provide the analytical work necessary to drive process improvement.
- Review and analyze claim denials in order to perform the appropriate appeals necessary for reimbursement.
- Receives denied claims and researches appropriate appeal steps
- Communicates directly with the payor, resubmits denied claims, underpaid claims and claims that are inaccurately processed by auditing accounts to check on proper payments, coding, balances, adjustments, etc. and also using appropriate reports and working queues
- Tracks and documents all denials by payor, visit type and denial category
- Identifies, documents, and communicates trends in recurring denials and recommends process improvements or system edits to eliminate future denials
- Under the direction of leadership works with necessary departments (e.g., Case Management, Medical Records, Patient Access, PFS Resolution Team, etc.) in order to drive process improvement and system edits.
- Works with the payors to understand specific reasons for denials and preventable measures available to prohibit future denials.
- Reviews monthly system report for the Denials Management Leadership Team
- Prepares an analytical summary report identifying areas of concern by dollar amount, volume and new denials
- Tracks improvement of targeted denials once process or system edits have developed to reduce/prevent future denials
KNOWLEDGE, SKILLS AND ABILITIES
- Knowledge of the current healthcare climate, including managed care developments, HIPAA standards and governmental program regulations
- Knowledge of current coding practices in regards to billing and processing of Explanation of Benefits. Insure that proper reimbursement has been received
- Excellent oral and written communication skills
- Ability to use a Windows based computer system and common business software found in Microsoft Suite (Excel, PowerPoint, Outlook etc.)
- Ability to work independently to effectively and efficiently perform assigned duties
- Ability to manage multiple priorities and deadlines
- Ability to identify, review, analyze, interpret, and present complex data; and to use creative thinking and logic to investigate and solve problems including making recommendations to outside departments to eliminate future problems.
EDUCATION AND EXPERIENCE
- Associate s degree in billing, coding, business, finance or related field required; equivalent work experience may be substituted for education.
- Minimum 3 years experience working with commercial or government billing and reimbursement processes required
Children's Hospital & Medical Center - Omaha