Denial Management Specialist-Cert CPFSS (HB)

Job Summary:

Under the direction of the PB Follow Up & Denial Team Supervisor, the PB Follow Up & Denial Team Member is responsible for monitoring claims for Medicare, Medicaid, Government Payors, Commercial Payors and Work Comp Payors through claim follow up and insurance appeals.

Essential Job Duties:

1. Researches and analyzes denial data and coordinates denial recovery responsibilities.
2. Identifies, analyzes, and researches frequent root causes of denials and recommends corrective action plans for resolution of denials.
3. Prioritizes activities to work overturns in a timely manner to alleviate untimely filings.
4. Uses WQ sort/filter options to categorize denials to work to overturn denials.
5. Researches, responds, and documents insurer correspondence /inquiry notes regarding coding, coverage, benefits, and reimbursement on patient accounts timely and accurately.
6. Makes management aware of any issues or changes in the billing system, insurance carriers, and/or networks.
7. Helps with coverage for Customer Service when needed.
8. Receive a passing score on the annual competency evaluation.
9. Demonstrates knowledge of patient confidentiality and HIPAA regulations.
10. Organized; sets priorities; meets deadlines
11. Demonstrates knowledge of assigned payor processes for follow up and denials and is able to navigate the payor provider portals easily.
12. Is a team player and communicates well with others.
13. Must obtain CPFSS (Certified Patient Financial Service Specialst) certification within 3-6 months upon hire date.
14. Uses sort/filter options to determine priority of working claims in the Follow Up WQ by timely filing deadline and balance.

Secondary Job Duties That May be Reassigned:

1. Process payor refunds
2. Answers and directs phone calls
3. Updates job knowledge by participating in educational opportunities
4. Complete Wellness Matters adjustments
5. Print paper claims and document claim run totals
6. Attach electronic medical records to claims in Waystar

Job Specifications:

• Education: High School graduate, associate’s degree preferred
• Experience: Insurance knowledge and terminology, understanding of medical terminology, knowledge of CPT, HCPCS and ICD10 coding, knowledge of credentialing workflow, knowledge of medical billing and collection practices, knowledge of working with EHR/EMR, proficient in spelling, grammar, punctuation, and other language skills. Proficient in keyboarding, data entry, and business writing. Practices efficient methods for getting work done; strong ability to prioritize workload. Organized and has the ability to work independently.