Denials Analyst

Job Title: Denials Analyst

Job Summary: As a Denials Analyst, you will be responsible for investigating and resolving claim denials from insurance companies or other payers. Your primary focus will be to analyze denial reasons, communicate with insurance providers or relevant parties, and take necessary actions to appeal or correct denied claims. This role requires strong analytical skills, attention to detail, and effective communication abilities to ensure timely resolution of denials and maximize revenue for the organization.

Responsibilities:

1. Denials Investigation:

   • Review and analyze denied claims to identify reasons for denial.
   • Verify claim information and compare against payer policies and contracts.
   • Determine appropriate action steps for resolving denials.

2. Communication:

   • Collaborate with insurance companies, payers, and other relevant parties to gather necessary information and resolve claim denials.
   • Communicate denial reasons and necessary actions to internal stakeholders, including billing teams, clinicians, and management.

3. Appeals Management:

   • Prepare and submit appeals for denied claims within specified deadlines.
   • Compile supporting documentation and evidence to strengthen appeal cases.
   • Track and monitor appeal statuses, following up as needed to ensure timely resolution.

4. Documentation and Reporting:

   • Maintain accurate records of denial reasons, actions taken, and outcomes.
   • Generate reports on denial trends, root causes, and appeal success rates.
   • Provide insights and recommendations for process improvements to reduce denials.

5. Quality Assurance:

   • Conduct thorough reviews of denied claims to identify patterns or trends.
   • Participate in quality assurance initiatives to enhance claim submission accuracy and minimize denials.

6. Training and Support:

   • Provide training and support to internal teams on denial prevention strategies and best practices.
   • Serve as a subject matter expert on denial management processes and payer requirements.

Qualifications:

• Bachelor's degree in Healthcare Administration, Business Administration, or related field preferred.
• Previous experience in healthcare revenue cycle management, medical billing, or claims processing.
• Strong understanding of medical terminology, coding systems (e.g., ICD-10, CPT), and insurance billing practices.
• Proficiency in using billing software, electronic health records (EHR), and Microsoft Office applications.
• Excellent analytical skills with the ability to interpret complex denial reasons and payer policies.
• Effective communication skills, both verbal and written, with the ability to negotiate and collaborate with external parties.
• Detail-oriented with a focus on accuracy and thorough documentation.
• Ability to work independently and prioritize tasks in a fast-paced environment.
• Familiarity with healthcare compliance regulations and HIPAA guidelines.
• Certified Professional Biller (CPB) or Certified Revenue Cycle Specialist (CRCS) credentials a plus.