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: 38683
About Cook Children's Health Care System
Cook Children's Health Care System is a not-for-profit, nationally recognized pediatric health care organization comprised of eight entities – a Medical Center, Physician Network, Home Health company, Northeast Hospital, Pediatric Surgery Center, Health Plan, Health Services Inc., and Health Foundation.Cook Children's Medical Center Based in Fort Worth, Texas, the integrated system has more than 60 primary and specialty care offices throughout North Texas. Its service region includes Denton, Hood, Johnson, Parker, Tarrant and Wise counties, with an additional referral area encompassing nearly half the state.Cook Children's traces its roots back to 1918, but throughout its continual change and robust growth, it still embraces an inspiring promise – to improve the health of every child in its region through the prevention and treatment of illness, disease and injury. To live up to this promise, Cook Children's combines the art of caring with the use of leading technology and extraordinary collaboration to provide exceptional care for every child, every day.History – Cook Children's has a rich history of nearly a century of caring for children.Our Promise – Knowing that every child's ...life is sacred, it is the promise of Cook Children's to improve the health of every child in our region through the prevention and treatment of illness, disease and injury.Companies – Based in Fort Worth, Texas, Cook Children's is a not-for-profit organization that is comprised of eight nationally recognized companies.Community Health Outreach – Cook Children's Community Health Outreach works together with over 150 partner organizations to improve the safety and health of at-risk children through education, disease and injury prevention and support.Clinical Research – Cook Children's is home to a skilled team of research-minded physicians, nurses and health care professionals and administrators who drive our commitment to excellent clinical care and the search for medical advances.Public Relations – Cook Children's Public Relations works with national and local media outlets, produces Cook Children's publications, coordinates special events and helps develop key relationships within the community.Contractor & Vendor Information – Cook Children's contractors and vendors must ensure their employees are knowledgeable about working with our organization.Sponsorship guidelines – Cook Children's sponsors a select number of events that are strongly aligned with its promise to improve the health of every child in the region through the prevention and treatment of illness, disease and injury.