Denials Specialist 1

Overview

The Denials and Insurance Follow-Up Specialist is responsible for managing denied claims, following up with insurance payers, and ensuring accurate reimbursement for hospital services. This role is critical to optimizing revenue recovery by investigating, correcting, and resubmitting denied claims while working closely with the Revenue Cycle Management (RCM) team to identify and address patterns in denials. The ideal candidate will have strong analytical skills and experience in medical billing and insurance follow-up, with a focus on reducing accounts receivable days and improving cash flow.

Responsibilities

Denial Management:

Review and analyze denied claims to determine the cause of denial, coordinating with coding, billing, and clinical staff as needed to gather additional information or correct claim errors.

Prepare and submit appeal documentation for denied claims, following up with payers to ensure resolution within timely filing limits.

Track, document, and report denial reasons, resolution actions, and outcomes, identifying patterns and trends that require additional training or process improvements.

Insurance Follow-Up:

Conduct timely follow-up on unpaid claims with insurance companies, ensuring that all accounts are resolved or escalated within the hospital’s standard timeframes.

Verify insurance eligibility and benefits as needed to validate patient coverage and support claims correction or resubmission.

Communicate effectively with insurance representatives to resolve outstanding issues, confirm payment status, and clarify discrepancies in payments or coverage.

Account Reconciliation and Resolution:

Reconcile accounts to ensure payments align with expected reimbursement, identifying and addressing underpayments, overpayments, or unapplied funds.

Work closely with the RCM team to adjust accounts, apply payments accurately, and resolve balances on patient accounts after denial or underpayment resolution.

Reporting and Analysis:

Generate and analyze regular reports on denial rates, follow-up activities, and recovery outcomes to provide insights into common denial reasons and support improvement strategies.

Collaborate with management to develop and implement best practices for denial prevention, appeal success rates, and insurance follow-up efficiency.

Qualifications

 Qualifications:

• Education:

• High School Diploma or General Education Degree (GED) or 3 years’ experience in healthcare setting required.

• Experience:
• Minimum six (6) months clerical experience required.
• Prior experience do physician/provider professional fee billing is preferred.  
• Familiarity with payer requirements, denial codes, and appeals processes for a range of insurance plans, including Medicare, Medicaid, and commercial payers.
• Skills and Abilities:
• Strong knowledge of healthcare claims processing, insurance reimbursement, and medical terminology.
• Proficiency with electronic health record (EHR) and revenue cycle management (RCM) software.
• Excellent analytical skills with the ability to identify root causes of denials and recommend corrective actions.
• Detail-oriented with excellent organizational and time management skills, ensuring timely follow-up and adherence to deadlines.
• Strong verbal and written communication skills, able to effectively interact with insurance
• Strong communication and interpersonal skills to coordinate effectively with team members and external partners.
• Able to analyze problems and strategize for better solutions
• Ability to read and comprehend instructions, short correspondence and memos. 
•  Ability to effectively present information in one on one and small group meetings to clients and staff.
• Able to Multi-tasking, prioritization, time management and critical thinking skills required.
• Proficient computer skills, Microsoft Office Suites. 
• Must be able to use personal transportation to provide courier services for the office.

DCH Standards:

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.

• Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.

• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned.

WORKING CONDITIONS

Physical presence onsite is essential with possibility of hybrid work schedule. Hearing and vision must be normal or corrected to within normal range.  Able to perform the duties with or without reasonable accommodation.

Valid driver’s license and automobile liability insurance. Very good interpersonal communication and customer service skills required.  

Physical:  Medium work – Exerting 20 – 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to more objects.  Physical Demand requirements are in excess of those for Light Work.   Good manual and finger dexterity.  Ability to tolerate prolonged periods of sitting.  Some light driving required. 

Psychological:  Contact with Others, Deal with external customers/clients, sometimes dealing with unpleasant people, occasionally coordinating letters/memos, working with work groups or as a Team constantly/consistently.