DENIALS SPECIALIST

Overview: The Denials Specialist is responsible for investigating and resolving denied insurance claims, ensuring timely resolution and optimal reimbursement for professional services performed at outpatient, urgent care or physician offices at Covenant HealthCare. This position will monitor and analyze quality of coding, compliance issues, billing, documentation and reimbursement and interpretation.

Demonstrates excellent customer service performance in that his/her attitude and actions are at all times consistent with the standards contained in the Vision, Mission and Values of Covenant HealthCare and the commitment to Extraordinary Care for Every Generation. Responsibilities:

• 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.

Qualifications:

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/SKILLS/ABILITIES

• 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.
•  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.