KPC GLOBAL MEDICAL CENTERS INC

The Denials Management Specialist is responsible for validating dispute reasons following Explanation of Benefits (EOB) review, escalating payment variance trends or issues to management, and generating appeals for denied or underpaid claims.. Coordinate with the Clinical Resource Center (CRC) for clinical consultations or account referrals when necessary,. and compile necessary supporting documentation for appeals, Terms & Conditions for FINThrive adjudication issues, and referral to refund unit on overpayments.. Perform research, makes determination of corrective actions, and takes appropriate steps to code the Denials Management System and route account appropriately.. Intermediate knowledge of hospital billing form requirements (UB-04)

management specialist

Job Description Job Description The Denials Management Specialist is responsible for validating dispute reasons following Explanation of Benefits (EOB) review, escalating payment variance trends or issues to management, and generating appeals for denied or underpaid claims. DUTIES AND RESPONSIBILITIES
Include the following. Others may be assigned.
Validate denial reasons and ensures coding in DCM is accurate and reflects the denial reasons. Coordinate with the Clinical Resource Center (CRC) for clinical consultations or account referrals when necessary,
Participate in payor JOC
Ability to trend issues and provide recommendations for resolution.
Interprets insurance program procedures and provisions to resolve routine insurance billing inquires and problems.
Documents clearly and concise account notes on all action taken on accounts
Work with various department in order to resolve issues and able to provide timely feedback
Must be able to pay attention to detail and have high quality of work.
Able to maintain daily workload by meeting the standard productivity
Understand DOFR
Generate an appeal based on the dispute reason and contract terms specific to the payor. This includes online reconsiderations.
Follow specific payer guidelines for appeals submission
Escalate exhausted appeal efforts for resolution
Work payer projects as directed
Research contract terms/interpretation and compile necessary supporting documentation for appeals, Terms & Conditions for FINThrive adjudication issues, and referral to refund unit on overpayments.
Perform research, makes determination of corrective actions, and takes appropriate steps to code the Denials Management System and route account appropriately.
Escalate denial or payment variance trends to leadership team for payor escalation.
Attends meetings as required
Other duties as assigned SKILLS & ABILITIES REQUIREMENTS:
Intermediate understanding of Explanation of Benefits form (EOB), Managed Care Contracts, Contract Language and Federal and State Requirements
Intermediate knowledge of hospital billing form requirements (UB-04)
Intermediate understanding of ICD-9, HCPCS/CPT coding and medical terminology
Intermediate Microsoft Office (Word, Excel) skills
Advanced business letter writing skills to include correct use of grammar and punctuation. REQUIREMENTS
EDUCATION / EXPERIENCE
High School Diploma or equivalent, some college coursework preferred
3 - 5 year experience in a hospital business environment performing billing and/or collections #J-18808-Ljbffr

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