The Denial Specialist will be responsible for reviewing all insurance claim denials and will take all steps necessary to make corrections or insurance appeals.
Every Adelante employee will strive to maximize their performance and contribution to Adelante Healthcare and the community we serve every day. Employees are expected work in a manner that demonstrates a commitment to quality, patient safety, employee engagement, innovation, and the highest standards of personal integrity, professionalism and competence.
OUR CORE VALUES
ESSENTIAL SKILLS AND EXPERIENCE
- Associates degree preferred
- High school diploma or GED from an accredited institution required
- 5 years relative billing experience in large practice, preferably family practice, pediatrics or OBGYN specialties
- CPT4 and ICD10 coding knowledge
- Ability to read and understand explanation of benefits and ANSI/remark codes
- Ability to research correct coding policies/guidance and payer policies
- High attention to detail and the ability to multi-task
- Excellent written and verbal communication skills
- Excellent analytic and problem solving skills
- Demonstrated progressive advancement within the medical billing industry
- Experience with Microsoft Excel and Word
NONESSENTIAL SKILLS AND EXPERIENCE
- The ability to communicate in more than one language
The qualifications listed above are intended to represent the minimum skills and experience levels associated with performing the duties and responsibilities contained in this job description. The qualifications should not be viewed as expressing absolute employment or promotional standards, but as general guidelines that should be considered along with other job related selection or promotional criteria.
- Review denied claims to determine if corrected claims or appeals need to be sent
- Call payers to determine true reason for denial and inquire on what corrections need to be made
- Work with the coding team when necessary to make coding changes to submit corrected claims/appeals
- Stay current with payer trending as to how to submitted corrected claims and the appeal process
- Develop and maintain denial management process, including but not limited to, creation of appeal of letters and denial tracking
- Analyze root causes of denials
- Shares trending and feedback to reduce denials to management team
Additional Duties and Responsibilities
- Other duties as request or assigned
All employees are responsible for promoting and participating in interdisciplinary communication and collaboration to enhance the delivery of quality across the health care system. Employees should maintain an environment which supports and engages patients and co-workers in a caring team based model to promote wellness and improve health outcomes.
Adherence to Compliance and Code of Conduct
All employees are required to comply with Adelante Healthcare’s written standards, including its Compliance Program and Standards of Conduct, policies and procedures and reporting of any conduct that potentially violates Adelante’s legal or compliance requirements. Such compliance will be an element considered as part of the regular performance evaluation.
PHYSICAL DEMANDS AND WORK ENVIRONMENT
The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Physical demands: While performing the duties of this job, the employee may be required to sit for long periods of time, is required to stand, walk, use hands to handle or feel objects, tools or controls; reach with hands and arms; climb steps/stairs; balance; stoop, kneel, crouch or crawl; talk or hear; smell; manage stress as it relates to essential job functions. The employee must frequently lift and/or move up to 25 pounds without assistance, and may occasionally be required to lift or move up to 50 pounds with assistance. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.
Work environment: While performing the duties of this job, the employee is exposed to weather conditions prevalent at the time when traveling to various clinic sites. The noise level in the work environment is usually moderate. The employee may be subject to health hazards (contagious diseases, blood borne pathogens, etc.) when working in the clinic area.
In any organization or job, changes take place over time. Although an effort will be made to keep job-related information current, this is not an all-inclusive list of job responsibilities. Adelante Healthcare, Inc. reserves the right to revise or change job duties and responsibilities as the business need arises. In compliance with EEOC 29 CFR part 1630, if the essential functions of this position cannot be performed in a satisfactory manner by the employee, further accommodations shall be made if it does not constitute undue hardships upon this organization.