Denial Specialist, Professional Billing

Beth Israel Lahey Health•Cambridge, MA

2d•$22 - $30

About The Position

The Denial Specialist identifies, reviews, and interprets third-party payments, adjustments, and denials. The role initiates corrected claims and appeals, analyzes unresolved third-party and self-pay accounts, and contacts and negotiates with internal and external parties to support timely, maximum payment. The specialist applies insurance payments manually and electronically and works insurance overpayments, credits, and undistributed balances. The position works directly with the Billing Supervisor on complex issues and denials through independent research and assigned projects. The role monitors accounts receivable, analyzes work queues and system reports, reviews and corrects claim denials and edits, and pursues rebilling, appeals, corrections, refunds, and other account resolutions. It maintains communication with payor representatives, supports staff education to reduce recurring denials, and works with the cash team to resolve unapplied cash. The specialist also completes assigned projects, follows department procedures and turnaround standards, and contributes to process improvement and department efficiency.

Requirements

High school diploma.
Two to three years of experience in healthcare denials.
Working knowledge of third-party payor reimbursement, eligibility verification processes, and government and payor compliance rules.

Nice To Haves

Billing certification preferred.

Responsibilities

Monitor days in accounts receivable and analyze work queues and system reports; identify denial and non-payment trends and report them to the Billing Supervisor.
Navigate the hospital billing system to identify paid claims and the root causes of physician inpatient denials.
Respond professionally to incoming insurance and office calls and obtain information needed to resolve current or potential claims.
Build and maintain communication with third-party payor representatives to resolve claims issues.
Review CMS 1500 claim forms for the accuracy of procedure, diagnosis, demographic, insurance, and other information.
Review and correct claims, charge denials, and edits reported through Epic, EOBs, insurer correspondence, or other sources; initiate rebilling, written appeals, corrections, and submissions needed to resolve accounts and obtain payment.
Use information from denials and edits to educate PFS and office staff and help prevent recurring issues.
Evaluate delinquent third-party accounts and process them under established protocols for review, payment plans, or write-off.
Review and update accounts for write-offs and refunds.
Follow through on insurance credit balances, including take-back and refund initiation or payment reapplication.
Stay informed about federal, state, and managed-care contract regulations and maintain working knowledge of billing mechanics to determine patients’ portions due.
Complete assignments within turnaround standards and report unfinished assignments to the Billing Supervisor.
Handle incoming department mail as assigned.
Attend meetings and serve on committees as requested.
Maintain appropriate or exemplary audit results and meet or exceed productivity standards.
Provide ideas for process improvement within the Central Billing Office.
Assist the Billing Supervisor with complex claims issues, denials, appeals, and credits.
Work with the cash team to resolve unapplied cash.
Complete assigned projects and research.
Pursue professional growth through in-service meetings, education programs, conferences, and similar activities.
Follow job-related policies and procedures and protect the confidentiality of patient, budget, legal, and company matters.
Use equipment and reference materials carefully; perform routine cleaning and preventive maintenance and keep the work area clean and organized.
Refer complex or sensitive issues to the Billing Supervisor and report irregularities in the cash or denial posting process promptly.
Learn and accept new tasks as required, work where needed, and assist colleagues with daily tasks or special projects.
Perform similar or related duties as assigned or directed.