Denials Prevention Specialist

4 weeks ago

Wausau, United States GastroIntestinal Associates, SC Full time
Job DescriptionJob Description

Position Summary

The Denials Prevention Specialist is responsible for managing and preventing healthcare insurance claim denials by working denials timely, identifying the root cause, and assisting in implementing corrective measures to optimize the revenue cycle. This role involves collaboration with various departments to ensure accurate and timely claim submissions, appeal processes, and compliance with payer guidelines.


Essential Job Functions and Responsibilities

  • Analyzes denied claims to identify common reasons for denials, trends, and patterns.
  • Presents findings and recommendations to Revenue Cycle Coordinator.
  • Works with the Revenue Cycle Coordinator to streamline workflows and improve efficiency in claim submission and follow-up processes.
  • Contacts insurance companies and other agencies regarding patient issues, benefits, or claim concerns by attending payor meetings.
  • Prepares and submits appeals and reconsideration for denied claims.
  • Collaborates with insurance companies to resolve denied claims and secure reimbursement.
  • Maintains accurate and detailed records of denial prevention activities and outcomes.
  • Maintains up-to-date knowledge of rules and regulations for medical billing. Maintains detailed and thorough knowledge of payer-specific laws and requirements to submit claims in a legal and compliant manner.
  • Performs other duties as assigned.

Minimum Qualifications

  • Education
    • High school diploma or equivalent required.
  • Licensure/Certification
    • Advanced training/certification in medical billing, coding, and/or insurance preferred.
  • Experience
    • Minimum of three-years' experience in a medical billing role is required, or equivalent education.

Competencies Required

  • Knowledge
    • Working knowledge of medical and insurance terminology.
    • Basic knowledge of CPT, HCPCS, and ICD-10 coding.
  • Skills
    • Possesses interpersonal, communication, and listening skills necessary to deal effectively and courteously with patients and all staff members.
    • Proficient computer skills working in an Electronic Medical Record (EMR) and Practice Management software, and Microsoft Word, Excel, and the Internet.
    • Demonstrates professionalism and respect in all forms of communication and correspondence.
    • High level of accuracy and efficiency when entering patient financial and related data.
  • Abilities
    • Ability to maintain strict confidentiality of fiscal and health information.
    • Ability to work in a fast paced, multi-tasking environment and cope with rapidly changing demands while working as a team member.
    • Ability to prepare and gather information accurately and efficiently.


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