Job Details

Denial Specialist

When you join the growing BILH team, you're not just taking a job, you're making a difference in people's lives.

The Denial Specialist will identify, review, and interpret third-party payments, adjustments, and denials. Initiates corrected claims, appeals, and analyzes unresolved third-party and self-pay accounts, initiating contacts and negotiating appropriate resolution (internal and external) to ensure timely and maximum payment. Manually and electronically applies for insurance payments and works insurance overpayments, credits, and undistributed balances. Works directly with the Billing Supervisor to resolve complex issues and denials through independent research and assigned projects.

Essential Duties & Responsibilities including but not limited to:

• Monitors days in A/R and ensures that they are maintained at the levels expected by management. Analyzes work queues and other system reports. Identifies denial/non-payment trends and reports them to the Billing Supervisor.
• Ability to navigate the hospital billing system to identify paid claims or root causes of denial when assessing physician inpatient denials.
• Respond to incoming insurance/office calls with professionalism and help resolve callers' issues, retrieving critical information that impacts the resolution of current or potential future claims.
• Establishes relationships and maintains open communication with third-party payor representatives to resolve claims issues.
• Review claim forms for the accuracy of procedures, diagnoses, demographic, and insurance information, as well as all other fields on the CMS 1500.
• Reviews and corrects all claims/charge denials and edits that are communicated via Epic, Explanation of Benefits (EOB), direct correspondence from the insurance carrier or others and uses information learned to educate PFS and office staff to reduce future denials and edits of the same nature. Initiates claim rebilling, written appeals, or corrections, and obtains and submits information necessary to ensure account resolution/payment.
• Evaluate delinquent third-party accounts and processes based on established protocols for review, payment plan, or write-off.
• Review/update all accounts for write-offs and refunds.
• Reviews and follows through on all insurance credit balances through take-back initiation, refund initiation, and/or payment re-application.
• Keeps informed of all federal, state, and managed care contract regulations, and maintains working knowledge of billing mechanics to properly ascertain patients' portion due.
• Completes all assignments per the turnaround standards. Reports unfinished assignments to the Billing Supervisor.
• Handles incoming department mail as assigned.
• Attends meetings and serves on committees as requested.
• Maintains appropriate audit results or achieves exemplary audit results. Meet productivity standards or consistently exceed productivity standards.
• Provides and promotes ideas geared toward process improvements within the Central Billing Office.
• Assists the Billing Supervisor with the resolution of complex claims issues, denials, appeals, and credits.
• Works with the cash team to resolve unapplied cash.
• Completes projects and research as assigned.

Secondary Functions:

• Enhances professional growth and development through in-service meetings, education programs, conferences, etc.
• Comply with policies and procedures as they relate to the job. Ensure confidentiality of patient, budget, legal, and company matters.
• Exercises care in the operation and use of equipment and reference materials. Performs routine cleaning and preventive maintenance to ensure the continued functioning of equipment. Maintains work area in a clean and organized manner.
• Refers complex or sensitive issues to the attention of the Billing Supervisor to ensure corrective measures are taken in a timely fashion.
• Observe irregularities in the cash/denial posting process and report them immediately to the Billing Supervisor.
• Accepts and learns new tasks as required and demonstrates a willingness to work where needed.
• Assists other staff as required in the completion of daily tasks or special projects to support the department's efficiency.
• Performs similar or related duties as assigned or directed.

Minimum Qualifications:

• Education: High School diploma required
• Licensure, Certification & Registration: Billing Certification preferred
• Experience: 2 3 years of experience in healthcare denials.
• Skills, Knowledge & Abilities: Working knowledge of third-party payor reimbursement, eligibility verification process, and government and payor compliance rules.

As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) as a condition of employment.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled