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Denials Edits Outpatient

2019-06-26 USD 60000.0000 62000.0000 Contract 2021-09-24
  • Job Id:

  • Profession:

  • Hiring Organization:

  • Employment Type:

5810 Coral Ridge Drive, Suite 250 Coral Springs FL 33076 USA
customer support [+954-656-8600]
  • Specialty:

  • 321 Main St.


    Warren, OH 44481WarrenOH
  • Start date:

    call for details
  • Salary:

    60,000 - 62,000


JOB SUMMARY  Denial Resolution Specialist is responsible to ensure all initial third party and federal/state government hospital claims are billed and all unpaid, rejected or denied claims receive appropriate follow up or an appeal to over-turn the denial as required. This position is responsible to accurately and timely prepare and submit all clean claims or corrected claims to payers via the claims scrubber or paper. Take action required to resolve pre billing claim holds. Resolve rejected, underpaid and denied claims by submitting corrected claims and appeals on a timely basis upon review of unpaid encounters. The position is required to identify and resolve complex claims issues adversely impacting the revenue cycle and achieve resolution through coordination with other Revenue Cycle departments, clinical departments and the payer with accurate and timely correction of all pending claims to payers.

• Processes third party and federal/state government claims based on payer billing regulations and requirements, coordination of benefits, combine rules, reimbursement, timely filing, interpretation of rejection and denial notifications, including appeal requirements in accordance with current federal, state, managed care or third party payer guidelines and claims edit requirements. Documents all actions in applicable computer system.
• Effectively complete NCCI and CCI Edits.
• Effectively utilizes systems including host computer system and billing scrubber with understanding of billing edits (stopping claims from billing) and reports to resolve accounts in order to decrease unbilled claims, claims on hold or denied and improve claims submission rates.
• Works to identify and obtain missing authorizations for specific patient episodes of care. Refers claims for HIM (Medical Records) to review coding and for medical necessity requirements. Recognizes missing charges and refers to nurse auditor to determine accuracy of charge posting.
• Serves as the resource for billing and reimbursement questions or issues from other Revenue Cycle departments or clinical departments.
• Identifies complex claims issues adversely impacting the Revenue Cycle. Identifies trends with payers, regarding denials, rejections, new requirements for coding, system issues causing delays in claims processing, documents and reports to revenue cycle management to provide feedback to contracts manager, other departments and insurance companies.
• Identifies root cause of rejection or denial using critical thinking to analyze claims data. Provides root cause feedback to Revenue Cycle leadership to prevent future rejections or denials.
• Stays current on all billing and associated information from industry publications and payer webinars.
• Identifies and updates missing information in the computer system to prevent future claims from stopping or denials.
• Maintains required levels of productivity and quality while managing tasks in work queues or reports to ensure timeliness of follow-up, appeals and resolution of debit or credit balances.
• Follow up on unpaid claims via web based payer sites, payer web portals or contacting insurance directly to successfully receive reimbursement or overturn payer denials. Verifies accuracy of insurance balances including credit balances for resolution.
• Interacts with multiple hospital departments, providers, third party payers or government agencies to facilitate resolution of unpaid, denied or rejected claims.
• Supports the department as needed to ensure services performed positively impact the revenue cycle.
• Ensures confidentiality of all patient accounts by following HIPAA guidelines.
• Participates in general or special assignments and other duties as assigned.

EDUCATION, EXPERIENCE AND QUALIFICATIONS • High School diploma or GED is required.
• Associate Degree in a related field preferred.
• Minimum of two or more years work experience with one or more of the following: Coding, third party claims billing, insurance follow up, denials management, underpayments, managed care contracts, cash application, credit resolution, audit, claims processing and revenue cycle compliance in a hospital, physician's, medical service organizations or health system revenue cycle department is preferred.
• Must have working knowledge and experience interpreting third party payer rules to include coordination of benefits, interpreting policy benefits, interpret contracts, state and federal regulations, overturning denials and underpayments and payment methodologies (DRG, case rates, revenue codes, fee for service) and remain current on all industry changes in billing requirements..
• Working knowledge of medical terminology, ICD9 & ICD10, HCPCS, CPT codes and revenue codes for billing is required.
• Organizational and time management skills and ability to work independently.
• Ability to effectively gather and exchange information in both oral and written communications.
• Detail oriented, analytical skills, root cause analysis, ability to problem solve and recommend resolutions.
• Ability to use MS Office Suite (Word, Excel, Outlook) at an intermediate level.

Other Requirements:
• Remote Workstation.
• Standard Window PC
• Internet Access with DSL or Cable.
• VPN compatibility.
• Microsoft Office/Word, Excel, Power Point.
• Printer/Fax.
• Remote location often working from a home office base.
The successful candidate will possess the following:

• Must be AHIMA or AAPC certified and hold one or more of the following certifications: RHIA, RHIT, CCS, CCS-P, CPC-H. • Must have a minimum of 5 years of coding experience.
• Successful completion of required ICD-10 training prior to start date.

Registered Health Information Administrator (RHIA). Registered Health Information Technician (RHIT), or Certified Coding Specialist (CCS).
MedPartners HIM Quick Facts:
• Ranked as a "Best Staffing Firms to Work for in 2017" by Staffing Industry Analyst
• Winner of Inavero's 2016 Best of Staffing Talent Diamond Award
• 6th Year Diamond selection to the "Best of Staffing Talent List" by CareerBuilder and Inavero
• Selected to the prestigious "Best of Staffing Client List" by CareerBuilder and Inavero
• "Best Places to Work for Millenials" winner
• Ranked among the 2017 Largest Staffing and Talent Engagement Firms in the US by Staffing Industry Analysts.
• Listed among "2017 Largest Healthcare Staffing Firms in the U.S.", by SIA.
• Made Staffing Industry Analyst's "2017 Largest Allied Healthcare Staffing Firms in the U.S.".
• Announced in SIA's, "2017 Fastest-Growing Staffing Firms in the U.S." listing.
• Recognized as an AHIMA Gold Business Partner and AHIMA Educational Partners


MedPartners HIM offers a full benefits package, including; PTO, Medical, Dental, Life and Long/Short term disability Insurance, Association Dues Paid, Educational Benefits and a Personal Improvement Benefit. Contact us to learn about our Bonus programs

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