Denial Management Specialist

Current Opening•Jamestown, ND

7d•Onsite

About The Position

The Denial Management Specialist receives, reviews, investigates, and refers denials, grievances, and appeals. The role gathers claim information from medical records, notes, invoices, and other sources; prepares appeal summaries; and ensures compliance with organizational standards and regulatory requirements. The position is full-time, working 80 hours per two-week pay period, typically Monday through Friday from 8:00 a.m. to 4:30 p.m., or four 10-hour shifts. The posting states there are no nights, weekends, or holidays, though it also notes the employee may be required or requested to work shifts other than the one for which hired. The position also supports insurance enrollment and billing operations, payment posting, clearinghouse account and posting error resolution, missing remittance research, website access setup for payments, prior authorization and insurance verification, and incoming telephone coverage. The employee interacts with adolescent, adult, and geriatric patients. The role works in a well-lit office that may have crowded work areas, temperature discomfort, and noise, and uses multiple workstations and a variety of equipment. The employee participates in and complies with the JRMC Safety Management Program and observes Standard Precautions and aseptic techniques when appropriate.

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.
Ability to gather and interpret data in unusual situations and solve complex problems.
Good organizational skills.
Ability to exercise independent judgment; errors may have moderate consequences.
Social sensitivity and effective communication with the public and coworkers; compliance with behavior standards.
Ability to manage own work.
Ability to speak and write English understandably.
Good general health and emotional stability.
Visual acuity necessary to perform routine procedures.
Ability to concentrate amid distractions and think clearly under pressure; work regularly requires a high level of mental and visual effort.
Ability to occasionally move computer paper and forms weighing a maximum of 50 pounds.
Ability to occasionally reach, stoop, bend, kneel, and crouch; constant sitting is required for the major responsibilities.
Punctual and regular attendance; report as scheduled, on time, prepared to work, and remain for the entire work schedule.
Complete a comprehensive background check as a condition of employment.
Complete a urine drug screening within 30 days of the hire date.
Physical requirements may be subject to reasonable accommodation; inability to meet one or more requirements does not automatically disqualify a candidate or employee.

Nice To Haves

High school-level education is preferred.

Responsibilities

Review, interpret, and analyze insurance claim denials to identify causes such as medical policy, missing authorization, or coding issues.
Work with insurance companies to provide accurately completed forms and documents needed to maintain facility enrollment and billing standing, within insurer deadlines.
Collaborate with billers, prior authorization specialists, coders, and providers to appeal denials.
Submit appeal letters and required documentation for all denial levels 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 an insurance plan or state.
Gather and complete special appeal or review forms.
Coordinate phone 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 or notifying 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 handled.
Assist with payment posting, resolve clearinghouse account and posting errors, locate missing remittances, and help set up website access for payments.
Provide backup support to the Prior Authorization/Insurance Verification team.
Act as backup for incoming telephone calls as needed.
Perform Insurance Biller duties as needed.
Perform other related duties as assigned or requested.
Maintain punctual and regular attendance and remain at work for the scheduled work period.
Participate in and comply with the JRMC Safety Management Program; maintain knowledge of and observe Standard Precautions; practice aseptic techniques when appropriate.