Denial Management Specialist

Jamestown Regional Medical Center•Jamestown, ND

8d•$18 - $25

About The Position

The Denial Management Specialist receives, reviews, investigates, and refers insurance denials, grievances, and appeals. The role gathers claim information through medical-record reviews, notes, invoices, and other documentation, and prepares appeal summaries in compliance with organizational standards and regulatory requirements. It also supports insurance enrollment, payment posting, clearinghouse and posting error resolution, missing remittance research, website access setup for payments, prior authorization and insurance verification, incoming telephone calls, and insurance billing as needed. This is a full-time position working 80 hours per two-week pay period. The regular schedule is Monday through Friday, 8:00 a.m. to 4:30 p.m., or four 10-hour shifts. The position does not require nights, weekends, or holidays.

Requirements

High school-level education preferred; computer and/or secretarial skills.
One year of clerical experience with computer knowledge, including more than three months of progressively more responsible experience.
Three months of on-the-job training.
Punctual and regular attendance; report as scheduled, be prepared to work, and remain for the entire work schedule.
Ability to gather and interpret data in unusual situations and solve complex problems; good organizational skills.
Ability to exercise independent judgment.
Social sensitivity and effective communication with the public and coworkers; compliance with behavior standards.
Ability to manage own work.
Ability to concentrate amid distractions and think clearly under pressure; the work regularly requires a high level of mental and visual effort.
Ability to speak and write English understandably.
Good general health and emotional stability.
Visual acuity necessary to perform routine procedures.
Ability to occasionally move computer paper and forms weighing up to 50 pounds; occasional reaching, stooping, bending, kneeling, and crouching; constant sitting is required for the major responsibilities.
A comprehensive background check is required as a condition of employment.
A urine drug screening is required for all positions and must be completed within 30 days of hire.
Ability to meet the stated physical requirements, subject to possible reasonable accommodation.

Responsibilities

Review, interpret, and analyze insurance claim denials to determine their causes, such as medical policy, missing authorization, or coding issues.
Work with insurance companies to submit accurately completed enrollment forms and documents within required timeframes, maintaining the facility’s standing to bill those insurers.
Work with billers, prior authorization specialists, coders, and providers to appeal denials.
Respond to all levels of denials by submitting appeal letters and required documentation within payer deadlines.
Review case history, payer history, and state requirements to determine appeal strategy.
Obtain patient and/or physician consent and medical records when required by the insurance plan or state.
Gather and complete special appeal or review forms.
Coordinate telephone hearings with the insurance company, patient, and physician.
Comply with first-, second-, third-, and external-level appeal processes.
Meet appeal filing deadlines by completing assigned worklist tasks promptly and reporting to management when assistance is needed.
Report insurance company or state requirements and denial trends to the PFS Manager and Reimbursement Specialist.
Participate in team and appeal meetings and share details of cases worked.
Assist with payment posting, resolve clearinghouse account and posting errors, find missing remittances, and help set up website access for payments.
Provide backup support to the Prior Authorization/Insurance Verification team.
Interact with patients in adolescent, adult, and geriatric age groups while performing duties.
Provide backup coverage for incoming telephone calls as needed.
Perform Insurance Biller duties as needed.
Perform other related duties as assigned or requested.