Complex Denials Consultant
About The Position
R1 is the leading provider of technology-driven solutions that transform the patient experience and financial performance of hospitals, health systems and medical groups. We are the one company that combines the deep expertise of a global workforce of revenue cycle professionals with the industry’s most advanced technology platform, encompassing sophisticated analytics, AI, intelligent automation, and workflow orchestration. As our Complex Denials Consultant, you will represent and counsel healthcare providers in their disputes with medical insurance carriers and managed care organizations at all stages of the administrative appeals process. Every day, you will handle contract review and appeal template development based on contractual provisions and applicable state and federal laws, writing appeals and letters to insurance companies to resolve denials, and reviewing high-balance or complex accounts. To thrive in this role, you must maintain a foundational understanding of Commercial, Governmental, Managed Care, and ERISA regulations regarding payment, coverage, conditions of participation, and other relevant topics.
Requirements
- Law degree from an accredited college or university.
- Barred in one state or must be bar-eligible within 6 months of graduation.
Nice To Haves
- Foundational understanding of Commercial, Governmental, Managed Care, and ERISA regulations regarding payment, coverage, conditions of participation, and other relevant topics.
Responsibilities
- Assist recovery staff in pursuing appeals, including the development of new and innovative legal and procedural arguments and tools.
- Draft complex and contractual appeals and letters to insurance companies.
- Review and apply client contract language and rates to resolve denied claims.
- Utilize payer-provider and administrative manuals to dispute denied claims.
- Contact provider representatives or higher-level resolution units to resolve complex claim and appeal issues.
- Represent clients during Administrative Law Judge hearings as needed.
- Assist with the training of recovery staff team members and provide necessary feedback as requested by management.
- Apply provider-specific reimbursement methodologies, payment policies, and provider contracts to fully confirm payment.
Benefits
- Annual bonus plan at a target of 10.00%
- Competitive benefits package
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Ph.D. or professional degree
