DENIALS SPECIALIST III

The Denials Specialist III is responsible for analyzing, managing, and resolving denied claims at Riverside Healthcare. This role involves reviewing high value technical denied claims to identify root causes, developing strategies to address and appeal denials, and implementing process improvements to reduce the frequency of denials for all payers. The Denials Specialist III works closely with billing, coding, and revenue cycle teams to ensure accurate and timely claim resolution. The role requires strong analytical skills, a deep understanding of payer policies, and effective communication skills to interact with insurance companies and internal stakeholders.

Essential Duties

• Review and analyze technical denied claims to determine the reason for denial and potential for resolution.
• Collaborate with billing and coding teams to gather necessary documentation and information for appeals.
• Monitor and track the status of denied claims and appeals, ensuring timely follow-up and resolution.
• Assist in maintaining detailed records of denial trends, appeal outcomes, and related activities for reporting and analysis. 
• Stay informed about basic changes in payer policies, coding guidelines, and industry regulations that may impact claim denials and resolution.
• Identify patterns and root causes of claim denials to develop effective corrective actions and prevent future issues. 
• Develop and submit appeal letters to insurance companies, utilizing accurate data and thorough explanations to support claim adjustments. 
• Work with payer representatives to resolve complex denial issues. 
• Provide recommendations for process improvements to enhance claim submission accuracy and reduce denial rates.
• Participate in training sessions and workshops to stay updated on best practices and industry standards.
• Lead the analysis of denial trends, identifying systemic issues, and advising leadership on strategic initiatives to improve revenue cycle efficiency.
• Mentor and provide guidance to junior specialists, assisting in complex denial cases and appeals. 
• Work all technical denials specific, but not limited to, inpatient, outpatient surgeries, and high-cost drugs greater than $2,000 reimbursement. 
• Proficiently pull and send in medical records for payer audit requests.
• Drive cross-functional projects related to revenue cycle management and claim denial prevention, ensuring alignment with organizational goals. 
• Review with leadership findings, trends, and recommendations for policy changes and process improvements. 
• Represent Riverside Healthcare in discussions with key payer representatives, advocating for favorable resolutions and policy clarifications. 
• Reviews and validates refund requests for outpatient accounts. 
• Average productivity of around 100 accounts a week. 

Non-essential Duties

• Continuously update knowledge on industry standards and best practices. 
• Support cross-functional teams with ad-hoc reporting and data analysis as needed.
• Assist with special projects related to revenue cycle management and claim denial prevention. 

Preferred Experience

• 5+ years of experience in claims management, denial analysis, or revenue cycle operations within a healthcare setting.
• In depth knowledge of payer policies, medical coding (ICD-10, CPT, HCPCs), and healthcare reimbursement processes.
• Advanced analytical skills with a strategic mindset and leadership experience. 
• Proficiency in claims management software, electronic health records, and data analysis tools (Epic preferred).
• Exceptional communication skills, with the ability to present complex information to senior management and external stakeholders. 

Required Licensure/Education

• High school diploma or equivalent required.

Preferred Education

• Bachelors degree in Healthcare Administration, Business, Finance, or a related field; Masters degree preferred.

Employee Health Requirements

Exposure to: 

• Chemicals: None 
• Video Display Terminals: Extreme 
• Blood and Body Fluids: None 
• TB or Airborne Pathogens: None

Sensory requirements (speech, vision, smell, hearing, touch): 

• Speech: Needed for presentations/training, telephone communication, facilitate meetings. 
• Vision: Needed to read memos and literature. 
• Smell: N/A 
• Hearing: Needed for telephone communications, meetings, and listening to employee concerns. 
• Touch: Need to write, do computer entry, filing. 

Activity/Lifting Requirements 

Percentage of time during the normal workday the employee is required to: 

• Sit: 85% 
• Twist: 0% 
• Stand: 5% 
• Crawl: 0% 
• Walk: 5% 
• Kneel: 0% 
• Lift: 2% 
• Drive: 0% 
• Squat: 1% 
• Climb: 0% 
• Bend: 1% 
• Reach above shoulders: 1% 

The weight required to be lifted each normal workday according to the continuum described below: 

• Up to 10 lbs: Occasionally 
• Up to 20 lbs: Occasionally 
• Up to 35 lbs: Not Required 
• Up to 50 lbs: Not Required 
• Up to 75 lbs: Not Required 
• Up to 100 lbs: Not Required 
• Over 100 lbs: Not Required 

Describe and explain the lifting and carrying requirements. (Example: the distance material is carried; how high material is lifted, etc.): Lifting is not usually required. 

Maximum consecutive time (minutes) during the normal workday for each activity: 

• Sit: 408 
• Twist: 0 
• Stand: 24 
• Crawl: 0 
• Walk: 24 
• Kneel:0 
• Lift: 9 
• Drive: 0
• Squat: 8 
• Climb: 0 
• Bend: 8 
• Reach above shoulders: 4 

Repetitive use of hands (Frequency indicated): 

• Simple grasp up to 10 lbs. 
• Normal weight: 5- 10lbs frequent 
• Pushing & pulling Normal weight
• Fine Manipulation: Terminal entry, calculator. 

Repetitive use of foot or feet in operating machine control: None 

Environmental Factors & Special Hazards 

• Environmental Factors (Time Spent): 
• Inside hours: 40 
• Outside hours : 0 
• Temperature: Normal Range 
• Lighting: Average 
• Noise levels: Average 
• Humidity: Normal Range 
• Atmosphere: Dust &Poor Ventilation 

Special Hazards: 

Protective Clothing Required: None