Claim Denial Specialist

This role is a direct hires only, we appreciate independent recruiters and per our policy we kindly request NO solicitations (Billing Companies) or Staffing Agencies during the hiring process.

IN PERSON POSITION ONLY

NO REMOTE CANDIDATES WILL BE ACCEPTED

About the Role:

The Claim Denial Specialist plays a critical role in the health care services industry by managing and resolving denied insurance claims to ensure timely reimbursement for medical services rendered. This position requires a thorough understanding of insurance policies, billing procedures, and regulatory compliance to identify the root causes of claim denials and implement effective solutions. The specialist collaborates closely with insurance companies, healthcare providers, and internal billing teams to appeal denials and prevent future occurrences. You will have the opportunity to work with a diverse patient population and make a meaningful impact on their healthcare experience. This is a Full-time (40 hours per week) position Monday to Friday from 8am to 5pm, and 1 Saturday per month 9am to 5pm.

Minimum Qualifications:

• High school diploma or equivalent; associate degree or Certification in medical billing and coding (e.g. CPC, CCS-P) preferred.
• Minimum of 3 years experience in medical billing, coding, or claims processing department with strong AR account follow-up, appeals, and coding knowledge is a must.
• Strong knowledge of medical insurance policies, claim submission processes, and denial reasons.
• Experience obtaining Prior-Authorization/Precertification for diagnostic testing
• Knowledge in obtaining insurance verification coverage benefits
• Billing experience in an Internal Medicine and/or Family Medicine setting
• Proficiency with eClinicalWorks, (EHR) systems and medical billing software.
• Advance skills in Microsoft Office, specifically Excel and Word.
• Excellent communication skills for interacting with insurance companies and healthcare providers.

Preferred Qualifications:

• Certification such as Certified Professional Coder (CPC) or Certified Medical Reimbursement Specialist (CMRS).
• Experience working with Medicare, Medicaid, and private insurance claim denials.
• Familiarity with healthcare regulations including HIPAA and the Affordable Care Act
• Experience working with healthcare insurance CPT, ICD codes, and documentation
• Understanding of payer websites eligibility, precertification, and appeal process by all payers including commercial and government payers such as Medicaid, Tricare, Medicare Advantage Plans.
• Strong research and analytical skills. Must be a critical thinker.
• Advanced skills in data analysis and reporting tools.
• Demonstrated ability to lead process improvement initiatives related to claims management.

Responsibilities:

• Review and analyze denied insurance claims to determine the reasons for denial and identify necessary corrective actions.
• Prepare and submit appeals and supporting documentation to insurance companies to resolve claim denials.
• Collaborate with healthcare providers, billing departments, and insurance representatives to gather information and clarify claim details.
• Maintain accurate records of denied claims, appeals, and outcomes to track trends and improve denial management processes.
• Monitor insurance policies and industry regulations to ensure compliance and update internal procedures accordingly.
• Generate reports on denial rates, resolution times, and financial impact to inform management decisions.
• Create claims charge entry, and post patient payments accurately
• Responsible for identifying missing payments, overpayments, and analyzing credits on accounts
• Identify patient balances, generate statements and coordinate payment plans as necessary
• Provide administrative support, answering phones, and scheduling appointments
• Back up to Front Office Team, assist with check-in process, collect patient payments, update insurance demographics and ensure patients update PCP as required.
• Other duties as assigned

Skills:

The Claim Denial Specialist utilizes analytical skills daily to dissect complex claim denials and identify patterns that inform corrective actions. Strong communication skills are essential for negotiating with insurance representatives and collaborating with internal teams to gather necessary documentation. Attention to detail ensures accuracy in reviewing claims and preparing appeals, minimizing errors that could delay reimbursement. Proficiency with billing software and EHR systems enables efficient management of claim records and tracking of denial resolutions. Ability to multi-task, strong analytical and mathematical skills. Additionally, knowledge of healthcare regulations and insurance policies guides compliance and helps the specialist implement best practices that reduce future denials.

Benefits:

401K/ Profit Sharing/ Medical, Vision, Dental Insurance, Life Insurance, Short and Long Term Plans