Denials Specialist I - Practice Advantage

• Denial Management:
• Review and analyze denied claims to determine the cause of denial, coordinating with coding, billing, and clinical staff as needed to gather additional information or correct claim errors.
• Prepare and submit appeal documentation for denied claims, following up with payers to ensure resolution within timely filing limits.
• Track, document, and report denial reasons, resolution actions, and outcomes, identifying patterns and trends that require additional training or process improvements.
• Insurance Follow-Up:
• Conduct timely follow-up on unpaid claims with insurance companies, ensuring that all accounts are resolved or escalated within the hospital’s standard timeframes.
• Verify insurance eligibility and benefits as needed to validate patient coverage and support claims correction or resubmission.
• Communicate effectively with insurance representatives to resolve outstanding issues, confirm payment status, and clarify discrepancies in payments or coverage.
• Account Reconciliation and Resolution:
• Reconcile accounts to ensure payments align with expected reimbursement, identifying and addressing underpayments, overpayments, or unapplied funds.
• Work closely with the RCM team to adjust accounts, apply payments accurately, and resolve balances on patient accounts after denial or underpayment resolution.
• Reporting and Analysis:
• Generate and analyze regular reports on denial rates, follow-up activities, and recovery outcomes to provide insights into common denial reasons and support improvement strategies.
• Collaborate with management to develop and implement best practices for denial prevention, appeal success rates, and insurance follow-up efficiency.

• Education:

• High School Diploma or General Education Degree (GED) or 3 years’ experience in healthcare setting required.

• Experience:

• Minimum six (6) months clerical experience required.
• Prior experience do physician/provider professional fee billing is preferred.
• Familiarity with payer requirements, denial codes, and appeals processes for a range of insurance plans, including Medicare, Medicaid, and commercial payers.
• Skills and Abilities:

• Strong knowledge of healthcare claims processing, insurance reimbursement, and medical terminology.
• Proficiency with electronic health record (EHR) and revenue cycle management (RCM) software.
• Excellent analytical skills with the ability to identify root causes of denials and recommend corrective actions.
• Detail-oriented with excellent organizational and time management skills, ensuring timely follow-up and adherence to deadlines.
• Strong verbal and written communication skills, able to effectively interact with insurance
• Strong communication and interpersonal skills to coordinate effectively with team members and external partners.
• Able to analyze problems and strategize for better solutions
• Ability to read and comprehend instructions, short correspondence and memos.
• Ability to effectively present information in one on one and small group meetings to clients and staff.
• Able to Multi-tasking, prioritization, time management and critical thinking skills required.
• Proficient computer skills, Microsoft Office Suites.
• Must be able to use personal transportation to provide courier services for the office.

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.

• Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.

• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned.

DCH Health System