Denials Specialist

Opelousas General Health System•Opelousas, LA

About The Position

Responsible for validating dispute reasons following Explanation of Benefits (EOB) review, escalating payment variance trends or issues to Business Services Director and/or generating appeals for denied or underpaid claims. ESSENTIAL DUTIES AND RESPONSIBILITIES Include the following. Others may be assigned. Validate denial reasons and ensures coding is accurate with HIM department and reflects the denial reasons. Coordinate with the Case Management department for clinical consultations or account referrals, when necessary, Generate an appeal based on the dispute reason and contract terms specific to the payor. This includes online reconsiderations. Follow specific payer guidelines for appeals submission. Escalate exhausted appeal efforts for resolution. Work payer projects as directed. Research contract terms/interpretation and compile necessary supporting documentation for appeals, Terms & Conditions for Internet enabled Managed Care System adjudication issues, and referral to refund unit on overpayments. Perform research and makes determination of corrective actions and takes appropriate steps to note the EMR system and route account appropriately. Escalate denial or payment variance trends to manager and/or director for payor escalation. Participate in workflow efficiency improvement efforts.

Requirements

Intermediate understanding of Explanation of Benefits form (EOB), Managed Care Contracts, Contract Language and Federal and State Requirements
Intermediate knowledge of hospital billing form requirements (UB-04)
Intermediate understanding of ICD-10, HCPCS/CPT coding and medical terminology
Intermediate Microsoft Office (Word, Excel) skills
Advanced business letter writing skills to include correct use of grammar and punctuation.
Associate’s degree and/or some college coursework or considerable work experience preferred.
3 - 5 years experience in a hospital business or equivalent environment performing billing, collections, coding and/or insurance appeals.
Ability to sit and work at a computer terminal for extended periods of time.

Responsibilities

Validate denial reasons and ensures coding is accurate with HIM department and reflects the denial reasons.
Coordinate with the Case Management department for clinical consultations or account referrals, when necessary
Generate an appeal based on the dispute reason and contract terms specific to the payor.
This includes online reconsiderations.
Follow specific payer guidelines for appeals submission.
Escalate exhausted appeal efforts for resolution.
Work payer projects as directed.
Research contract terms/interpretation and compile necessary supporting documentation for appeals, Terms & Conditions for Internet enabled Managed Care System adjudication issues, and referral to refund unit on overpayments.
Perform research and makes determination of corrective actions and takes appropriate steps to note the EMR system and route account appropriately.
Escalate denial or payment variance trends to manager and/or director for payor escalation.
Participate in workflow efficiency improvement efforts.