We are seeking a dedicated and detail-oriented Claims Denial and Appeals Specialist. This role is responsible for researching and resolving claim denials, handling ADR requests and certifications, submitting and tracking appeals, identifying trends, and generating monthly reports. The specialist will respond to audit requests (including RAC) from payors, maintain a comprehensive library of payer reference material regarding requirements for pre-authorization, medical necessity, and documentation, and collaborate with Revenue Cycle stakeholders to share insights on denials and opportunities for preventing future denials.

Qualifications:

Education:

• Required: High School diploma or equivalent
• Preferred: Associate degree

Licensure/Certification:

• Preferred: Certified coder or currently enrolled in a coding program

Experience:

• Required: Minimum of two years of professional billing experience with an emphasis on managed care denial follow-up and appeals processing. Prior hospital billing experience is a plus.
• Preferred: Three to five years of patient accounting experience in a high-volume environment.

Specific Skills, Knowledge, Abilities Required:

• Strong analytical skills
• Proficient in Microsoft Windows with a strong emphasis on Excel
• Ability to prioritize and coordinate workflow with great attention to detail
• Knowledge of CPT, HCPC, and ICD-10 coding requirements with an emphasis on modifiers and diagnosis association
• Working knowledge of LCDs, NCCI, and MUE edits
• General knowledge of commercial, HMO, and Medicare Advantage claims, including authorization and documentation requirements

Key Responsibilities:

• Research and resolve claim denials
• Handle ADR requests and certifications
• Submit and track appeals
• Identify trends and generate monthly reports
• Respond to audit requests from payors, including RAC audits
• Maintain a comprehensive library of payer reference material
• Collaborate with Revenue Cycle stakeholders to provide insights on denials and preventive measures

If you meet the above qualifications and are looking for a challenging and rewarding position, we encourage you to apply for this opportunity.