SHS-DENIAL RESOLUTION SPECIALIST-PROFESSIONAL CLAIMS

General Purpose of Job:

As part of the denial management team, follow up and resolve professional patient accounts that have been denied payment by the insurance carrier. Resolution will include root cause analysis in order to mitigate continued occurrences and lost revenue.

Essential Duties:

This job description is intended to cover the minimum essential duties assigned on a regular basis. Caregivers may be asked to perform additional duties as assigned by their leader. Leadership has the right to alter or modify the duties of the position.

• Work denied accounts in assigned work queue(s), reports, or as requested.
• Identify and research denial root cause and resolve account.
• Look for denial trends and escalate as necessary.
• Handle incoming and outgoing telephone calls with clinical departments and insurance companies.
• When identified, make recommendations related to process and system changes to support efficient compliant workflow.
• Responsible for providing leader with weekly statistics of worked accounts, reporting identified trends.
• Responsible for understanding Revenue Cycle compliance rules and regulations as it relates to billing and coding guidelines.
• Maintain confidentiality regarding patient bills & records.
• Review diagnostic and procedure coding of provider services according to established guidelines.
• Correlate diagnoses, procedures and modifiers with the medical billing system based on provider documentation.
• Assist with developing and maintaining policies/procedures for coding processes.
• Work with other Caregivers, providers, and insurance carriers to resolve coding issues for appropriate documentation and reimbursement.
• Responsible for knowledge and use of coding software and all other applicable research tools.
• Office work with the option to work at home if desired when appropriate.
• Primarily sedentary activities with some lifting of not more than 10 - 15 pounds required, twisting, bending, and reaching.