Denials Mitigation Specialist I

Full-time dayshift position offering a hybrid work schedule with approximately 3 days on-site per week.

Our business office is located at 8094 Sandpiper Circle, Nottingham, MD.

Under general direction the Denials Mitigation Specialist will provide ongoing review of technical denials, inpatient and outpatient claims. The specialist will review all reported accounts to determine root cause, training needs, appeal options and process steps. The specialist will manage the technical appeals process and personally handle complex appeal responses. The specialist will provide monthly updates to the Denials Mitigation Supervisor on the status of root causes, mitigation plans and appealed claims. The specialist will assist in the development of reimbursement error prevention program with the aim of decreasing the number of denied claims. Will work closely with representatives in other areas to ensure compliance with actions and reconciliation of results. Given the wide range of staff involved in the denial process the incumbent must be able to work collegially and respond efficiently and effectively. The specialist will work closely with the Denials Mitigation Supervisor to develop training opportunities and serve as a resource for Physician Practices, Patient Access, Prior Authorization and Hospital Ancillary Departments.

Primary Duties and Responsibilities

• Manage and resolve denials and appeals ensuring effective denial management and prompt reimbursement.
• Follow up on returned claims correspondence, denials account reconciliations and rebills. Monitors for timely follow up.
• Interpret and apply insurance payer guidelines, claim submission rules and contract terms.
• Provide cross-coverage for team members and maintain regular communication with management about denial findings.
• Keep organized references on coding insurance carriers, managed care networks and credentialing.
• Uses insurance tools, Payer websites and other eligibility tools as required.
• Deliverables include creation of tracking and trending reports with scope/responsibility of denials.
• Special consideration of prior authorization denials will include department responsibility reviews and education on referrals or other findings that will allow reimbursement to hospital.
• Distributes accounts to outpatient departments, responsible for obtaining insurance clearance with expectation that department responds with authorization or reason for no authorization. Tracks and trends all responses from these departments. Monitors for timely follow up.
• Works with the Managed Care Department and insurance companies to resolve insurance payment issues. Attends Payor meetings to review findings and coordinate policy reviews.
• In collaboration with internal and external colleagues, create cadence of timelines for denial and appeal processing and follow up.
• Fosters a collaborative environment and promotes a team approach to resolution of denials and mitigation plans.

Minimal Qualifications
Education

• High School Diploma or GED required
• Associate's degree preferred

Experience

• 1-2 years Experience in medical setting with strong insurance knowledge and medical coding. Patient Access, Prior Authorization and denials management experience preferred

Licenses and Certifications

• CHAA, CHAM or CRCS preferred preferred

Knowledge Skills and Abilities

• Requires some knowledge of Medical Terminology and CPT/ICD-10 coding.
• Requires basic working knowledge of UB04 and Explanation of Benefits (EOB).
• Working Knowledge in multiple specific payers' application billing and/or collection process.
• Verbal and written communication skills.
• Basic computer skills preferred.