Eligibility Denial Specialist III

UT Southwestern Medical Center • Dallas, TX

2d • Remote

About The Position

The Eligibility Denial Specialist III is responsible for researching any denied claim for both professional and hospital billing based on eligibility to ensure correct payers are billed timely on submitted insurance claims. The role will be responsible for managing and resolving outstanding correspondence related to refund requests from insurance carriers. This role involves reviewing refund requests, determining their validity, disputing questionable refunds, and communicating directly with insurance companies to resolve issues. The individual will also be tasked with completing dispute letters, conducting follow-ups, and handling appeals to ensure proper resolution of refund issues. Experience in insurance billing, registration, and a keen understanding of the refund process will be key to successfully managing these tasks. This position requires strong attention to detail, the ability to effectively communicate with insurance carriers, and a solid understanding of billing and refund processes within the healthcare industry. Serve as a team lead, handle complex and escalated refund matters, train and mentor staff, lead workflow activities, and assist the supervisor with operational needs and team support.

Requirements

• High School Diploma or equivalent
• 6 years medical billing, claims processing, and/or insurance eligibility experience.
• Experience with reviewing and resolving refund request correspondence from various insurance carriers.
• Knowledge and experience with submitting dispute letters to insurance carriers and following up to track the status of refund disputes.
• Knowledge and experience in processing and issuing refunds in compliance with company policies, along with a strong understanding of insurance billing practices and regulations to resolve billing discrepancies.
• Ability to communicate effectively with insurance carriers via phone or written communication to resolve refund issues.
• Experience with online payer portals to manage refund requests and disputes.
• Knowledge of registration processes to resolve issues impacting patient or insurance account details related to refunds.
• Ability to multitask and prioritize tasks effectively while handling multiple refund disputes and requests.
• Advanced experience researching and resolving complex or escalated refund requests, disputes, and appeals.
• Experience monitoring work queues, correspondence inventory, aging, productivity, and workflow priorities.
• Experience training staff and explaining refund processes, payer requirements, dispute documentation, and resolution steps.
• Ability to analyze refund trends, identify root causes, and recommend process improvements.
• Ability to lead workflow activities and assist with quality review and operational follow-up.
• Outlook experience
• Outlook Teams App experience
• Excel experience
• Medical Terminology
• Payer Portal experience
• Leadership and team coordination skills
• Ability to coach, train, and provide constructive guidance to team members
• Strong critical thinking, problem-solving, and decision-making skills
• Professional communication and collaboration skills
• Ability to remain organized, dependable, and adaptable while supporting multiple priorities

Nice To Haves

• May consider medical billing certifications or graduate degrees in lieu of experience.

Responsibilities

• Research denied insurance claims for professional and hospital billing based on eligibility through the billing system, including Medicaid, Medicare, Worker's Compensation, Mental Health payers, and third-party payers.
• Interpret Explanation of Benefits from insurance companies on denied claims.
• Contact payers via website, phone, and/or correspondence regarding claims denied for eligibility.
• Contact patients and assist with Coordination of Benefits or other coverage denials.
• Work in all professional billing service areas.
• Update registration and demographic information in all hospital billing service areas.
• Resolve eligibility denials in all clearinghouse and payer rejection WQ's.
• Review and resolve any Visit Filing order changes and work advanced Visit Filing Order WQ's.
• Function as a liaison between clinical departments and third-party payers.
• Complete special projects as requested.
• Identify problems and inconsistencies using management reports; summarize findings and make recommendations to resolve billing issues to maximize collections.
• Manage and resolve outstanding correspondence related to refund requests from insurance carriers.
• Review refund requests, determine their validity, dispute questionable refunds, and communicate directly with insurance companies to resolve issues.
• Complete dispute letters, conduct follow-ups, and handle appeals to ensure proper resolution of refund issues.
• Serve as a team lead, handle complex and escalated refund matters, train and mentor staff, lead workflow activities, and assist the supervisor with operational needs and team support.

Benefits

• PPO medical plan, available day one at no cost for full-time employee-only coverage
• 100% coverage for preventive healthcare-no copay
• Paid Time Off, available day one
• Retirement Programs through the Teacher Retirement System of Texas (TRS)
• Paid Parental Leave Benefit
• Wellness programs
• Tuition Reimbursement
• Public Service Loan Forgiveness (PSLF) Qualified Employer

What This Job Offers

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