Denials Management Specialist
1 day ago
We are seeking a highly skilled Denials Management Specialist to join our team at Bestcare (NY). As a key member of our revenue cycle team, you will be responsible for reviewing and resolving denials for commercial and government payers, as well as physician and facility claims.
Key Responsibilities- Analyze denials and apply applicable contract agreements, payer medical policy language, and NMHS coding and authorization processes.
- Ensure accurate payments and initiate corrective action with third-party payers.
- Demonstrate a deep understanding of contract and reimbursement language.
- Maintain a follow-up and reporting system to ensure receipt of reimbursement.
- Analyze and research contractual and reimbursement issues, and provide accurate information to internal and external sources.
- Correctly handle denials and resolve them in accordance with department policy.
- Timely follow-up on denials, appeals, and other related matters.
- Assist staff with work volume as needed and provide accurate information in response to special requests.
- Provide contract and payer recommendations, and participate in payer meetings to escalate issues.
- Assist with tracking payer agenda items and provide training on contracts and reimbursement to other areas as needed.
- High School Diploma or General Educational Development (G.E.D.) required.
- College coursework in accounting and/or healthcare preferred.
- Minimum 1-2 years of experience working for a third-party payer or healthcare provider required.
- Minimum 1 year of insurance billing experience preferred.
- Six months of institutional and professional ICD and CPT coding preferred.
- Six months of experience with DRG reimbursement and outpatient, including ASC grouper, ER, and outpatient reimbursement preferred.
- Experience in researching institutional and professional claims to determine correct contract reimbursement using payer contracts preferred.
- Proficiency in Microsoft Office, including Word, Excel, and Outlook.
- Ability to perform 10-key data entry.
- Strong verbal and written communication skills.
- Knowledge of medical terminology.
- Knowledge of patient accounting software and payer websites.
- Knowledge of Universal Billing (UB) and Healthcare Financing Administration (HCFA) billing formats.
- Knowledge of International Classification of Disease (ICD), Current Procedural Terminology (CPT), Revenue Codes, and understanding of DRG methodology.
- Knowledge of facility contracting rates.
- Knowledge of CMS (Center for Medicare and Medicaid Services).
- Knowledge of WPS ANSI remark codes.
- Ability to maintain confidentiality.
- Ability to read and understand payer explanation of benefits (EOB).
- Ability to use basic accounting and math principles.
- Ability to identify, trend, and analyze data.
- Ability to learn new software programs.
- Ability to organize and prioritize work.
- Ability to work independently.
- Ability to identify and trend issues to improve or streamline processes.
- Ability to maintain a professional demeanor with internal and external contacts.
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