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Denials Specialist (Sign On Bonus Eligible For Qualified Candidates)

  • Job ID 2005032152
  • Date posted 09/22/2020
  • Facility Conifer Health Solutions
Description:

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!

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.



Qualifications:

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!

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.

Job: Conifer Health Solutions
Primary Location: Lebanon, New Hampshire
Job Type: Full-time
Shift Type: Days