Job Summary

The Denial Recovery Specialist is responsible for the resolution of denied and/or underpaid medical claims. This role provides subject matter expertise on the root cause of denials and works them in a timely manner.

Essential Functions

• Identify, analyze, and research frequent root causes of denials and underpayments.

• Develop corrective action plans for resolution of denials.

• Prioritize activities to work denials and underpayments in a timely manner to alleviate untimely files.

• Communicate with management regarding any issues or changes in the billing system and/or payers.

• Document all denial and underpayment activity in the patient accounting system.

• Assist with monthly denial reporting.

• Create and process timely appeals in order to overturn denials.

• Comply with all policies, procedures, and related protocols as established by the organization.

• Participate in the continuous quality improvement process.

• Perform all other duties as assigned or required.

Experience Required

• More than 2 years of claims processing or claims auditing experience.

• Knowledge of billing guidelines and ICD-10, CPT, and HCPCS coding.

• Experience with Medicare and Medicaid billing guidelines and rules, insurance reimbursement methods, and the claims appeal process.

• Working knowledge of insurance explanation of benefits and denial codes.

• Understanding of managed care contracts and capitation payments.

• Computer proficiency in Word, Excel, Outlook, along with general knowledge of internet research and medical billing systems.

• Personal effectiveness and credibility.

• Confidentiality.

Skills and Abilities

• Use language and mathematical skills to analyze and interpret reports and related material.

• Use special record keeping procedures.

• Recognize errors in recorded information.

• Perform routine and repetitive work.

• Excellent computer skills.

• Knowledge of 3M Encoder.

• Medical terminology.

• Principles of disease.

• Use appropriate ICD-10 codes and CPT codes for diagnosis and procedures.

• Anatomy and physiology.

Physical Demands

Light work: Exerting up to 20 pounds of force occasionally for up to one-third of the time and/or up to 10 pounds of force occasionally for up to one-third of the time to move objects.

This role requires walking or standing to a significant degree, or requires sitting most of the time but entails pushing and/or pulling of arm or leg controls, or requires working at a production rate pace involving the constant pushing and/or pulling of material even though the weight of those materials is negligible.

Environmental Conditions

Work is performed indoors with protection from weather conditions, but not necessarily from temperature changes.

Reasoning Development

Ability to apply principles of rational systems to solve practical problems and deal with a variety of concrete variables. Ability to interpret instructions furnished in written, oral, or diagrammatic form.

Mathematical Development

No special computation skills are necessary. Basic mathematical skills and concepts will be utilized for patient payment needs and calculating care expenses.

Language Development

Reading: Read and understand instructions, safety rules, legal documents, and the components of medical records.

Writing: Write reports with proper format, punctuation, spelling, and grammar, using all parts of speech.

Speaking: Speak with poise, voice control, confidence, and respect, using correct English and a well-modulated voice.

Relationships to Data, People, and Things

Data: Compiling — gathering, collating, or classifying information about data, people, or things. Reporting and/or carrying out a prescribed action in relation to information are frequently involved.

People: Speaking-signaling — talking with and/or signaling people to convey or exchange information.

Things: Operating-controlling — starting, stopping, controlling, and adjusting the progress of machines or equipment. Operating machines involves setting up and adjusting the machine or materials as the work progresses. Controlling involves observing progress of operations and turning devices to regulate reactions of materials.