Denials Specialist - Contract

Conifer Health Solutions • Frisco, TX

18h • 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 contract terms, and researching contract interpretations. The specialist will also handle Terms & Conditions for adjudication issues and refer overpayments to the refund unit. Additionally, they will perform research to determine corrective actions, code the DCM system, and escalate denial trends to leadership.

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.
• Handle Terms & Conditions for Internet enabled Managed Care System (IMaCS) adjudication issues, and referral to refund unit on overpayments.
• Perform 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.
• 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