Denials and Appeals Specialist

Job Summary:

The Denials & Appeals Specialist is responsible for managing, tracking, and resolving denials and appeals to ensure timely reimbursement. This role requires in-depth knowledge of payer guidelines, systems, and requirements to navigate complex denial cases effectively, assist in issue resolution, and help identify trends that can improve claim outcomes.

Supervisory Responsibilities:

• None

Duties/Responsibilities:

• Monitors assigned queues and duties across various systems, to ensure all follow-up dates are current.
• Analyzes denials to determine appropriate actions, completes appeals, or routes cases for clinical appeals as needed.
• Files and monitors appeals to resolve payer denials, documenting all activity accurately and maintaining logs, account notes, and system records.
• Maintains an up-to-date understanding of payer guidelines and requirements related to denials and appeals.
• Processes internal requests, reviews Government Audit accounts, Payer refund requests related to overpayments and completes necessary rebills and adjustments.
• Identifies trends in denials to suggest improvements and reduce future claim issues, providing data for denial and appeal trends as needed.
• Assist with, complete, and provide coding and billing documentation to ensure accurate coding and billing practices to maximize revenue and minimize claim denials.
• Answer inquiries from patients.
• Maintain compliance with relevant regulations, including HIPAA, and payer-specific guidelines
• Perform other related duties to benefit the mission of the organization

Required Skills/Abilities: 

• Strong knowledge of payer guidelines, medical billing practices, and appeal processes
• Proficiency in relevant software and claims management systems, such as Meditech, Quadax and Athena a plus
• Excellent analytical skills for reviewing denial trends and suggesting improvements
• Strong verbal and written communication skills to interact with payers and internal departments
• Ability to prioritize tasks effectively and manage time in a fast-paced environment
• Intermediate computer skills, including but not limited to: Microsoft Office, electronic medical record, and email
• Strong command of / proficient in spoken and written English
• Strong attention to detail
• Ability to multi-task with multiple interruptions

Education and Experience:

• Highschool diploma or GED required; Associate Degree or higher in Health Information Management preferred
• 3+ years of experience in Hospital billing, revenue cycle, or claims denials and appeals processing required.
• Prior experience with revenue cycle processes in a hospital required. Physician practice experience a plus.

Physical and Mental Requirements: 

• Prolonged periods sitting at a desk and working on a computer
• Must be able to lift up to 25 pounds at times
• Must be able to navigate various departments of the organization’s physical premises
• Sufficient hearing, vision, and dexterity to perform duties safely
• Stress Level: Low to Moderate 

OSHA Classification:

• Category III: Tasks that involve no exposure to blood, body fluids, or tissues, and Category I tasks are not a condition of employment.
• The normal work routine involves no exposure to blood, body fluids, or tissues (although situations can be imagined or hypothesized under which anyone, anywhere might encounter potential exposure to body fluids). Persons who perform these duties are not called upon as part of their employment to perform or assist in emergency medical care or first-aid or to be potentially exposed in some other way. Tasks that involve handling implements or utensils, use of public or shared bathroom facilities or telephone, and personal contacts such as handshaking are Category III tasks.