EHPB Denial Management Spec

EvergreenHealth•Kirkland, WA

About The Position

The EHPB Denial Management Specialist investigates health plan denials to determine appropriate actions and resolve them. The role is in Professional Billing and works accounts meeting denial management criteria, including accounts with potential financial impact involving authorization and referral denials, bundling issues, and medical necessity for assigned payers. The specialist coordinates resolution with other departments, documents denial actions and outcomes, identifies denial patterns that may indicate process improvements, and produces quarterly denial reports.

Requirements

High school graduate or equivalent.
One year of previous experience in professional billing.
Knowledge and experience working with health care insurers and their reimbursement systems, especially Medicare, Medicaid, Workers Compensation, Motor Vehicle, and contract payers.
A good understanding of CPT, modifiers, HCPC, ICD-10 codes, and medical terminology.
Demonstrated problem-solving ability.
Ten-key by touch.

Nice To Haves

College degree or vocational training in billing or business.

Responsibilities

Investigate insurance denials to identify the necessary action.
Correct claims based on denials, complaints, and audits, then rebill using the payer-approved process.
Determine whether a payer appeal is needed, prepare an individualized appeal letter, and monitor appeals for resolution.
Adjust denials determined to be appropriate using the corresponding adjustment codes.
Work accounts that meet denial management criteria and coordinate resolution with other departments.
Log denials, actions, and resolutions in the Denial spreadsheet.
Identify denial patterns and potential process improvements.
Produce quarterly denial reports.