Clinical Denial Management Specialist III

UT Southwestern Medical Center•Dallas, TX

7d•Remote

About The Position

The Revenue Cycle Department team has a new opportunity available for the role of Clinical Denial Management Specialist I. Works under moderate supervision to perform intermediate level billing/denial responsibilities. The expectations for this position shall include but not be limited to the following: Three (3) years of follow-up / collections experience Review, research, and resolve denial of professional claims related to CPT codes, place of service, modifiers, and payer policies. Reconcile expected payment and make necessary adjustments as required by plan reimbursement. Review and interpret documentation. Prepare and submit appeals to payers based on payor guidelines. Contact payers regarding reimbursement of denied claims. Review accuracy of payment to account Resolve discrepancy between insurance and billing. Provide feedback on denial trends to leadership. Applicants must be able to work within a 100%25 metric centric environment. Shift: Flex shift, start time between 0600-0900. Work from home (WFH): This is a work from home position. Applicants must live in the state of Texas. Additional details shall be discussed as part of the interview process.

Requirements

High School Diploma Or equivalent or
3 years medical billing or collections experience.
Must demonstrate the ability to work clinical denials for complex E&M services, diagnostic studies, and/or minor surgical procedures
Must demonstrate a strong knowledge of medical claims recovery and/or collections rules and regulations

Nice To Haves

Coding certifications (CPC, CPMA, CMC, ART, RRA, RHIA, RHIT, CCS, CCA) and/or degrees (associate level, bachelor level, master level) are preferred and may be considered in lieu of experience.
(CPC) CERT PROFESSIONAL CODER Upon Hire or
(CPMA) Cert Prof Medical Auditor Upon Hire or
(CMC) CERT MEDICAL CODER Upon Hire or
(ART) ASSOC RECORDS ADMIN Upon Hire or
(RRA) REGISTERED RECORDS ADMIN Upon Hire or
(RHIA) REGD HEALTH INFO ADMINIST Upon Hire or
(RHIT) REGD HEALTH INFO TECHNOLO Upon Hire or
(CCS) CERT CODING SPECIALIST Upon Hire or
(CCA) Cert Coding Associate Upon Hire

Responsibilities

Review, research and resolve coding denials for complex diagnostic studies, endoscopic, interventional and/or major surgical procedures. This includes denials related to the billed E&M, CPT, diagnosis, and modifier. Denial types could include bundling, concurrent care, frequency and limited coverage. Prepare and submit claim appeals, based on payor guidelines, on complex coding denials. Identify denial, payment, and coding trends in an effort to decrease denials and maximize collections.
Contact payers, via website, phone and/or correspondence, regarding reimbursement of claims denied for coding related reasons. Interpret Managed Care contracts and/or Medicare and Medicaid rules and regulations to ensure proper reimbursement/collection.
Requires knowledge of carrier specific claim appeal guidelines. This includes Claim Logic, internet, and paper/fax processes. Requires proven analytical, and decision making skills to determine what selective clinical information must be submitted to properly appeal the denial. Requires proven knowledge of CPT and ICD-10 coverage policies, internal revenue cycle coding processes and the billing practices of the specialty service line. This position requires clear and concise written and oral communication with payors, providers, and billing staff to insure resolution of complex coding denials.
Requires the ability to read and interpret E&M notes, complex diagnostic study results, endoscopic and interventional results and/or major surgical operative notes. Based on the documentation review, confirm or change the billed CPT code(s), diagnosis code(s) and modifiers (if applicable) in order to attain denial resolution. Requires proven knowledge of the specialty specific service line documentation requirements. Must be familiar with the Medicare and Medicaid teaching physician documentation billing rules within 60 days of hire.
Serves as a resource to the FERC Team Leads, Compliance Auditors, Medical Collectors and MSRDP Clinical Denials Management Specialist I & II. Requires a billing and coding knowledge level that provides guidance on and resolution to resolve claim denials and rejections.
Makes necessary adjustments as required by plan reimbursement.
Duties performed may include one or more of the following core functions: (a) Directly interacting with or caring for patients; (b) Directly interacting with or caring for human-subjects research participants; (c) Regularly maintaining, modifying, releasing or similarly affecting patient records (including patient financial records); or (d) Regularly maintaining, modifying, releasing or similarly affecting human-subjects research records.
Performs other duties as assigned.

Benefits

PPO medical plan, available day one at no cost for full-time employee-only coverage
100%25 coverage for preventive healthcare-no copay
Paid Time Off, available day one
Retirement Programs through the Teacher Retirement System of Texas (TRS)
Paid Parental Leave Benefit
Wellness programs
Tuition Reimbursement
Public Service Loan Forgiveness (PSLF) Qualified Employer

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