Summary: The Denials Specialist is responsible for appealing and resolving claim denials. Responsibilities include: determining the root cause of the denial, appealing the denial, pursuing the payor for reconsideration, taking appropriate resolution steps, tracking recoveries, and successfully recovering denied amounts as efficiently as possible. Working under the direction of the Reimbursement Manager, the Denials Specialist assists in tracking and reporting payor denials and contract-related discrepancies. Denials are referred to the Denials Specialist via a denials work queue based upon the reason code provided by the payor on the remittance.
High School diploma or equivalent.
2 years hospital or physician revenue cycle or contracting experience required or 2 years of experience working for a health plan in a capacity that pays claims, handles appeals and/or reviews contract terms.
Ability to understand contract terms and calculate reimbursement.
Knowledge of the payor appeal timeframes, levels and operations in order to successfully maneuver payor operations.
Excellent written and oral communication skills to effectively appeal denials and communicate with payors and other departments.
Knowledge of healthcare related financial and/or accounting practices.
Ability to manipulate data using excel.
Ability to deal effectively with constant changes and be a change agent.
Detailed knowledge of health plan operations, reimbursement methodologies, payer contracts and clinical policies
Knowledge of state, federal and compliance regulations as they pertain to coding and billing processes and procedures.
Prior experience with Epic Systems Revenue Cycle Solutions preferreds and procedures.
Internal Number: 38057
About Cook Children's Health Care System
Cook Children's Health Care System embraces an inspiring Promise – to improve the health of every child in our region through the prevention and treatment of illness, disease and injury. Based in Fort Worth, Texas, we’re proud of our long and rich tradition of serving our community.