Claims Denial Specialist

 

Core Hours:  9:00 AM to 5:30 PM | On-site

 

• Monitor and manage denied, rejected, and underpaid laboratory claims from initial identification through resolution. 
• Research denial reasons and determine root causes, including eligibility, authorization, medical necessity, coding, modifier, bundling, documentation, timely filing, and payer-specific issues. 
• Review laboratory claims for appropriate CPT/HCPCS codes, ICD-10-CM diagnosis codes, modifiers, units, ordering-provider information, and other billing requirements. 
• Investigate payer policies and determine appropriate corrective action, rebilling, reconsideration, or formal appeal. 
• Prepare and submit accurate first-level and subsequent-level appeals, including supporting documentation and medical records when appropriate. 
• Track appeal deadlines, payer responses, outstanding balances, and expected reimbursement. 
• Communicate with payers regarding claim status, denials, payment discrepancies, and appeal determinations. 
• Identify recurring denial trends and recommend corrective actions to prevent future denials. 
• Review payer-specific requirements related to laboratory testing, medical necessity, prior authorization, coverage policies, and documentation. 
• Maintain accurate denial and appeal records and document all follow-up activities in the billing or practice-management system. 
• Escalate complex or high-dollar claims, payer disputes, compliance concerns, and potential contractual issues to management. 
• Assist with payer audits, reimbursement reviews, and revenue-cycle performance initiatives. 
• Meet established productivity, quality, appeal turnaround, and recovery targets. 
• Maintain confidentiality of patient and laboratory information in accordance with HIPAA and applicable organizational policies. 

• High school diploma or equivalent. 
• 3 years of experience in medical billing, claims follow-up, denial management, or revenue cycle management. 
• Working knowledge of healthcare claims and payer reimbursement processes. 
• Strong attention to detail and ability to analyze complex claim information. 
• Excellent written and verbal communication skills. 
• Ability to manage multiple accounts, deadlines, and payer requirements independently. 
• Proficiency with Microsoft Office and healthcare billing or practice-management systems. 

• Experience in a CLIA-certified laboratory, diagnostic laboratory, or other laboratory-focused healthcare organization. 
• Experience with Medicare, Medicaid, and commercial laboratory claims. 
• Knowledge of CPT, HCPCS, ICD-10-CM, and applicable modifiers. 
• Familiarity with laboratory medical-necessity policies and payer coverage requirements. 
• Experience with electronic claims, clearinghouses, payer portals, and appeals. 
• Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent certification. 

Additionally, the position requires the following knowledge, skills, and abilities: 

About Simple Laboratories 
Simple Laboratories is a Chicago-based growing clinical laboratory, and we're driven to set a new standard in healthcare for patient care and customer support. This means developing the most efficient processes, monitoring operations and test results tirelessly and making our services accessible to patients. We have a dedicated and passionate team of lab technicians, phlebotomists, sales, IT and administrative staff and are looking for a candidate who can make an impact on the organization. Our employees are engaged, collaborative and team focused, while working together to provide the best service to our clients and patients.