DENIALS SPECIALIST
- Analyze denied claims by identifying reasons for denial and verify claim information against payer policies and contracts.
- Resolve denials by determining appropriate actions and submitting appeals within specified deadlines.
- Compile supporting documentation and evidence to strengthen appeal cases, and maintain accurate records of denial reasons, actions taken, and outcomes.
- Generate reports on denial trends, root causes, and appeal success rates, providing insights and recommendations for process improvements to reduce future denials.
- Follows policies, procedures and guidelines to assure consistent coding quality. At the same time utilizes analytical skills when reviewing charts, interpreting documentation and applying codes, sufficing edits, etc.
- Provide training and support to internal teams on denial prevention strategies and best practices, serving as a subject matter expert on denial management processes and payer requirements.
- Utilizes numerous references to support technical decisions, clinical understanding of disease processes or procedures/tests performed.
- Adhere to coding rules for coding professional services for multiple specialties.
- Assure that all legal requirements, including Federal (HIPAA) and State regulations are met.
- Demonstrates an awareness of legal/confidentiality issues and adheres to all HIPAA Privacy and Security and
- Department Policies and Procedures.
- Participates in development and attainment of department and workgroup goals.
- Contributes to organizational success targets for patient satisfaction.
- Perform other duties as assigned.
EDUCATION/EXPERIENCE
Associate's degree in medical coding curriculum required.
Experience in professional coding setting/physician office setting and interpreting professional/physician remittance advice statements for all major insurance payers for multiple physician specialties preferred.
Certified Professional Coder (CPC) required and/or must be completed within 12 months of the start date.
- Knowledge of office equipment and computer use including EMR, Microsoft Outlook, Excel, Word, and other software, as needed (Intelicode, Systoc, AAPC, etc.).
- Knowledge/understanding of medical terminology and anatomy.
- Knowledge of third-party payer coding and billing reimbursement.
- Â Knowledge of ICD9/10CM diagnosis coding, CPT-4 coding and HCPCS coding guidelines.
- Demonstrates effective communication methods and skills, both verbally and in writing.
- Uses appropriate organization/priority setting skills to complete work timely and accurately.
- Practices effective problem identification and resolution skills as a method of sound decision making.
- Demonstrates interpersonal skills required to work with many other people and personalities.
- Requires the ability to use sound judgement, based upon the latest guidelines, federal and state statutes and regulations, as well as hospital and departmental policies.
- Ability to sit and look at computer screen for long periods of time.
- Ability to be flexible to adjust assignments as priorities change.
WORKING CONDITIONS/PHYSICAL DEMANDS
- Ability to maintain punctual attendance consistent with ADA, FMLA, and other federal, state, and local standards.
- Constant sitting, talking, hearing, near vision, and midrange vision.
- Occasional lifting up to 25 lbs.
- Frequent depth perception, visual accommodation, and color vision.
- Occasional standing, walking, twisting, reaching, feeling, and field of vision.
- Must be able to sit and type for long periods of time.
- Must be able to use the telephone for long periods of time.
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