Denials Specialist

Conifer Health Solutions • Frisco, TX

1d • Onsite

About The Position

Responsible for validating dispute reasons following Explanation of Benefits (EOB) review, escalating payment variance trends or issues to NIC management, and generating appeals for denied or underpaid claims. This role involves validating denial reasons, ensuring coding accuracy, coordinating with the Clinical Resource Center for consultations, generating appeals based on dispute reasons and contract terms, and performing research to determine corrective actions. The specialist will also escalate exhausted appeal efforts and work payer projects as directed. The position requires an intermediate understanding of Explanation of Benefits (EOB), Managed Care Contracts, Federal and State Requirements, hospital billing forms (UB-04), ICD-9, HCPCS/CPT coding, and medical terminology. Proficiency in Microsoft Office and advanced business letter writing skills are also necessary. Conifer requires candidates to obtain and provide confirmation of all required vaccinations and screenings prior to employment, which may include COVID-19, influenza, and other future required vaccines and screenings.

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-9, 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.
• High School Diploma or equivalent
• 3 - 5 years experience in a hospital business environment performing billing and/or collections

Nice To Haves

• some college coursework preferred

Responsibilities

• Validate denial reasons and ensures coding in DCM is accurate and reflects the denial reasons.
• Coordinate with the Clinical Resource Center (CRC) 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.
• Research and makes determination of corrective actions and takes appropriate steps to code the DCM system and route account appropriately.
• Escalate denial or payment variance trends to NIC leadership team for payor escalation.

Benefits

• Medical, dental, vision, disability, and life insurance
• Paid time off (vacation & sick leave) – min of 12 days per year, accrue at a rate of approximately 1.84 hours per 40 hours worked.
• 401k with up to 6% employer match
• 10 paid holidays per year
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee Assistance program, Employee discount program
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, AD&D, auto & home insurance.
• For Colorado employees, Conifer offers paid leave in accordance with Colorado’s Healthy Families and Workplaces Act.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED