Denials Specialist

Conifer Health Solutions • Frisco, TX

343d • $18 - $28

About The Position

The Denials Specialist is 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 coordinating with the Clinical Resource Center for consultations, generating appeals based on dispute reasons and contract terms, and following specific payer guidelines for submission. The specialist will also perform research on contract terms and escalate denial trends to leadership for resolution.

Requirements

• High School Diploma or equivalent, some college coursework preferred.
• 3 - 5 years experience in a hospital business environment performing billing and/or collections.
• Intermediate understanding of Explanation of Benefits form (EOB), Managed Care Contracts, 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.

Responsibilities

• Validate denial reasons and ensure coding in DCM is accurate.
• Coordinate with the Clinical Resource Center for clinical consultations or account referrals.
• Generate appeals based on dispute reasons and contract terms specific to the payor.
• Follow specific payer guidelines for appeals submission.
• Escalate exhausted appeal efforts for resolution.
• Work on payer projects as directed.
• Research contract terms and compile necessary supporting documentation for appeals.
• Perform research and determine corrective actions for coding in the DCM system.
• Escalate denial or payment variance trends to NIC leadership.

Benefits

• Medical, dental, vision, disability, and life insurance.
• Paid time off (vacation & sick leave) - minimum of 12 days per year.
• 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 including pet insurance, legal insurance, and long term care.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Industry: Ambulatory Health Care Services
• Education Level: High school or GED