Enterprise Claims Resolution Specialist

2 weeks ago


Gainesville, Florida, United States UF Health Shands Full time
Position Overview

The Enterprise Claims Resolution Specialist plays a crucial role in the assessment of technical denial claims and the submission of reconsiderations or appeals.

Reporting directly to the Enterprise Technical Denial Assistant Manager, this position is pivotal in enhancing the financial performance of the hospital's revenue cycle by ensuring a minimal denial rate and maximizing reimbursement rates at an enterprise level for UF Health Shands.


This role initiates a thorough root cause analysis of denied payments through various methods, including but not limited to: examining patient admissions and treatments, reviewing payer agreements, analyzing historical denial patterns, appeals, their outcomes, and identifying emerging trends in payer practices and requirements.

The specialist is responsible for nurturing relationships with third-party payers, addressing inquiries, complaints, and other correspondence.

In collaboration with the Enterprise Technical Denial Assistance Manager and the Enterprise Senior Denial Manager, this role maintains a strong partnership with the Enterprise Managed Care Department to escalate and resolve unusual denial issues.

A comprehensive understanding of state and federal regulations pertaining to contracts and the appeals process is essential.


The Enterprise Claims Resolution Specialist is recognized as a technical denial authority in denial management, ensuring that all denied claims are meticulously addressed from a technical and billing standpoint.

Collaboration with various revenue cycle departments across the enterprise is key to establishing best practice solutions aimed at maximizing reimbursement and minimizing organizational write-offs.

Qualifications

Minimum Education and Experience Requirements:

Education & Experience:
• High school diploma required, with four (4) years of experience in coding, billing, insurance follow-up, collections, or denial management within a hospital or clinical environment.
• An Associate’s degree or higher in a health or business-related field is preferred, along with three years of relevant experience in a hospital or clinical setting.

Knowledge, Skills, Abilities:
• Demonstrated knowledge of:

o Hospital billing and reimbursement processes
o Denials and appeals management
o Third-party payer contracts
o Federal and state regulations governing the healthcare sector
• Strong critical thinking and analytical capabilities
• Exceptional attention to detail with the ability to perform tasks with minimal errors and independently.
• Proficient organizational skills
• Excellent written and verbal communication skills
• Ability to prioritize tasks and manage time efficiently.
• Proficient in Microsoft Office Suite, including Outlook, Word, and Excel
• Familiarity with HIPAA guidelines
• Ability to read and interpret Explanation of Benefits (EOBs).
• Strong research and problem-solving abilities

Motor Vehicle Operator Designation:

Employees in this position:
Will not operate vehicles for business purposes.

Licensure/Certification/Registration:
None

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