DENIALS SPECIALIST II

The Denials Specialist II is responsible for analyzing, managing, and resolving denied claims at Riverside Healthcare. This role involves reviewing technical denied claims related to mid value technical denials to identify root causes and work said denials. The Denials Specialist II works closely with billing, coding, and revenue cycle teams to ensure accurate and timely claim resolution. This role requires effective communication skills to interact with insurance companies and internal stakeholders.

Essential Duties

• Review and analyze 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 disputes and 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.
• Work mid value technical denials including, but not limited to, outpatient surgeries, AIC, and CTC between $250 to $2,000 reimbursement.
• Proficiently pull and send in medical records for payer audit requests.
• Reviews and validates refund requests for outpatient accounts. 
• Average productivity of around 90 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.

Preferred Experience

• 2-5 years of experience in claims management, denial analysis, or revenue cycle operations within a healthcare setting.
• Basic knowledge of payer policies, medical coding (ICD-10, CPT, HCPCs), and healthcare reimbursement processes.
• Strong communication skills, both written and verbal, with the ability to interact effectively with insurance companies and internal teams.
• Ability to work under supervision, prioritize tasks, and manage time effectively. 

Required Licensure/Education

• High school diploma or equivalent required.

Preferred Education

• Associates degree in Healthcare Administration, Business, Finance, or a related field 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