Medical Denials Specialist

Position Overview

We are seeking an experienced Medical Denials Specialist, who brings an established foundation in medical denial management within a medical practice or healthcare revenue cycle environment and is interested in continuing to expand their knowledge and skills as part of a collaborative, growing practice.

Candidates should be comfortable working independently while also contributing effectively within a team environment. A minimum of three years of direct medical denial management experience is required for this position.

We currently have ten office locations across the upstate. Our providers care for patients at twenty-eight dialysis centers and multiple hospital locations throughout the Upstate. 

Position Details

Job Type: Full-time 

Location: In Office, 203 Mills Avenue Greenville, SC 29605

Schedule: Monday-Friday, 8:30a.m.- 5:00p.m.; 35-40 hours per week

Pay: $18.00-$21.00 per hour, based on relevant experience and qualifications

Benefits: 401(k), Paid Holidays, PTO, Dental/Health/Vision Insurance

Job Description

The Medical Denials Specialist is responsible for managing denied and outstanding professional claims assigned through various work queues based on payer, place of service, and denial type. The position requires thorough claim research, appropriate corrective action, consistent follow-up, and accurate account documentation to support timely and appropriate reimbursement.

Denial work encompasses professional claims across multiple settings, including physician offices, laboratories, hospitals, and dialysis centers. The position also includes reviewing and appropriately addressing payer correspondence received by mail, including appeal-related correspondence, claim denial information, and other denial-related communications.

The Medical Denials Specialist may also assist with shared departmental responsibilities, including answering incoming telephone calls, assisting patients with billing-related questions, and supporting team members as needed. 

Responsibilities

Claims & Denial Management

· Research and resolve denied claims by identifying root causes, making necessary corrections, obtaining supporting documentation, and submitting appeals, reconsiderations, disputes, or corrected claims as appropriate. 

· Monitor timely filing and appeal deadlines. 

· Follow up on outstanding claims and previously submitted appeals, disputes, reconsiderations, and corrected claims.

· Research claim status and denial issues through payer portals and direct payer communication as needed. 

· Investigate insurance-related denials involving eligibility, coverage dates, coordination of benefits, payer order, and changes in coverage to determine appropriate billing action.

· Review and interpret EOB and ERA information to identify denial reasons and determine appropriate next steps.

· Clearly document denial research, payer communications, actions taken, and required follow-up within the patient's account.

Patient Interactions

· Answering patient billing questions by phone or through MyChart messages.

· Contacting patients when additional information is required to resolve a claim or insurance-related issue, including but not limited to coordination of benefits. 

· Collecting patient payments by telephone.

· Updating and/or verifying patient insurance information within the patient's registration.

Essential Requirements

· Minimum of three years of direct medical denial management experience, including experience researching and resolving denied claims, preparing appeals, and submitting corrected claims.

· Knowledge of health insurance eligibility, coordination of benefits, payer order, and the impact of insurance changes on claim processing and reimbursement.

· Ability to read and interpret payer EOBs/ERAs and use denial information to determine the appropriate course of action.

· Ability to communicate denial trends, identify root causes, and present recommended resolutions to leadership when appropriate.

· Strong organizational, time-management, critical-thinking, and problem-solving skills.

· Ability to manage multiple work queues and prioritize accounts based on claim status, deadlines, and follow-up requirements.

· Willingness and ability to learn and adapt to changing payer requirements, billing guidelines, and practice processes.

· High school diploma or equivalency. 

Preferred Experience/Skills

· Epic experience.

· Familiarity with multiple insurance payer portals and electronic eligibility resources.

· Experience working professional claim denials with commercial, government and managed care payers. 

Carolina Nephrology, PA is an equal opportunity employer.