Denial Specialist

Job Details Job Location : Corporate Headquarters - Gary, IN Position Type : Full Time Education Level : High School Salary Range : Undisclosed Job Shift : Day Job Category : Finance

Description GENERAL DESCRIPTION:

The Prior Authorization/Denial Specialist is expected to demonstrate an attitude of teamwork by creating a relationship with patient accounts, health information services, finance, clinical managers as well as administration.The position should maintain a constancy of purpose and continuous education of payer billing compliance and reimbursement regulations, especially for Indiana Medicaid, Clinic Option and Medicaid Rehabilitation Option.

DUTIES AND RESPONSIBILITIES:

Responsibilities include daily and/or weekly review of payer denials. This requires logging all denial reasons, patient name, account number, program, service activity code and clinician.In addition, a constant review of government and payer bulletins and memorandums that are specific to billing and coding changes specific to behavioral health and addictions is required.

DIRECT DUTIES:

Constant review of all remittance advice and explanation of benefits for zero pays and denials.

Log all denials by reason code.

Address denial issues with management.

Monitor billing and medical policy notices from all payers.

Solicit assistance from clinical, health information and/or quality personnel to resolve denial issues.

Process and submit appeals when appropriate to all payers.

Ensure compliance with federal and state rules and regulations.

Provide education to clinicians, business office staff regarding Medicare, Medicaid and commercial reasons for denials.

Cross training to serve as a back up in the finance department when needed.

Promotes effective working relationship and work effectively as part of the department team to facilitate departmental goals and objectives.

Performs other duties as assigned.

ADMINISTRATIVE:

Maintain clinical and management records in accordance with assigned Services Programs.

Maintain 100% UM/UR compliance.

Other responsibilities and tasks as may from time to time be assigned.

GENERAL

Conduct all professional activity in an ethical manner.

Conform to all applicable policies and procedures.

In conjunction with other staff assist in identifying and eliminating any situation which jeopardizes the health and/or safety of clients, staff, or others who come in contact with community mental health center operations.

Utilize literature, workshops and other training aids to continually improve clinical and administrative skills.

In conjunction with supervisor, complete and implement Individual Professional Development Plan.

Assist in assuring Edgewater Health compliance with all related licensing and accreditation requirements.

SUPERVISED BY:

Accounts Receivable Director

WORKERS SUPERVISED:

None

Qualifications MINIMUM QUALIFICATIONS:

Education – Associate degree from an accredited college or university preferred. Completion of formal bookkeeping or accounting course work preferred.

Other – Experience with Medicare, Medicaid and Commercial insurance billing required.

Have knowledge of the healthcare industry specific to Center for Medicare and Medicaid Services (CMS) rules and regulations for behavioral health and addictions.

Prefer coding experience but not required.

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