Denials Specialist

Description

JOB SUMMARY

Responsible for validating dispute reasons following Explanation of Benefits (EOB) review, escalating payment variance trends or issues to NIC management, and generating appeals for denied or underpaid claims.

ESSENTIAL 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,
• 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 Internet enabled Managed Care System (IMaCS) adjudication issues, and referral to refund unit on overpayments.
• Perform research and makes determination of corrective actions and takes appropriate steps to code the DCM system and route account appropriately.
• Escalate denial or payment variance trends to NIC leadership team for payor escalation.

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• 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.

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.

EDUCATION / EXPERIENCE

Include minimum education, technical training, and/or experience preferred to perform the job.

• High School Diploma or equivalent, some college coursework preferred
• 3 - 5 years experience in a hospital business environment performing billing and/or collections

PHYSICAL DEMANDS

The physical demands 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.

• Ability to sit and work at a computer terminal for extended periods of time

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Call Center environment with multiple workstations in close proximity

As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities, and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost, and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

Compensation and Benefit Information

Compensation

• Pay: $18.60 - $28.00 hourly per hour. Compensation depends on location, qualifications, and experience.
• Position may be eligible for a signing bonus for qualified new hires, subject to employment status.
• Conifer observed holidays receive time and a half.

Benefits

Conifer offers the following benefits, subject to employment status:

• Medical, dental, vision, disability, and life insurance
• Paid time off (vacation & sick leave) – min of 12 days per year, accrue at a rate of approximately 1.84 hours per 40 hours worked.
• 401k with up to 6% employer match
• 10 paid holidays per year
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee Assistance program, Employee discount program
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, AD&D, auto & home insurance.
• For Colorado employees, Conifer offers paid leave in accordance with Colorado’s Healthy Families and Workplaces Act.