Remote Denials Management Jobs in Riverside, CA (NOW HIRING)

About Us

All Care To You is a Management Service Organization providing our clients with healthcare administrative support. We provide services toIndependent Physician Associations, TPAs, and Fiscal Intermediary clients. ACTY is a modern growing company which encourages diverse perspectives. We celebrate curiosity, initiative, drive and a passion for making a difference. We support a culture focused on teamwork, support, and inclusion. Our company is fully remote and offers a flexible work environment as well as schedules. ACTY offers 100% employer paid medical, vision, dental, and life coverage for our employees. We also offer paid holiday, sick time, and vacation time as well as a 410k plan. Additional employee paid coverage options available.

Job purpose

The Medical Billing Lead serves as a mentor and resource for Billing Coordinators, providing guidance, training, and support in reviewing professional medical claims. This role focuses on managing complex claims, including denials, underpayments, and appeals, requiring deep knowledge of reimbursement rules, billing requirements, and health plan processes. The Lead ensures accurate and timely resolution of pending, and unpaid claims by collaborating with insurance carriers, providers, and internal teams. The position plays a key role in maintaining client satisfaction, providing critical support to ensure the financial health of our clients and growth for our company. Strong written and verbal communication skills are essential for interacting with clients and insurance representatives.

Duties and responsibilities

• Claims Management:
  • Mentor other team members in the details of their assigned health plan, providing answers to questions and direction when needed.
  • Review provider escalations and provider resolution or escalation to management as needed.
  • Review complex patient accounts requiring identification of duplicate claims, corrected claims, overpayments, underpayments, and other issues and work them to resolution
  • Conducts timely and accurate follow-up on professional services claims to ensure all requested information has been submitted and claims are being processed utilizing payor portals, secure chat, secure messaging, and telephone calls.
  • Identifies missing payments from the health plan and assists in researching/locating payments.
  • Reviews incoming correspondence from health plans and takes appropriate action or escalates to designated team members as needed.
  • Identifies pending claims and determines next steps required to obtain reimbursement for claim.
  • Uses existing queries to review limited new denials for processing errors, appropriately assigns a status based on review, corrects any internal errors and resubmits claims as necessary.
  • Follows up with insurance carriers, providers, or other stakeholders to gather additional information or documentation required for claims resolution.
  • Monitors incoming messages from providers and responds to the provider or escalates the request to the appropriate team member.
  • Assist with special claims research projects as assigned.
  • All other duties as assigned.
• Communication:
  • Communicate effectively with insurance companies, healthcare providers, and their billing staff to resolve claims issues and answer inquiries.
  • Document all interactions and updates in the claims management system.
• Documentation and Reporting:
  • Maintain accurate records of claim status, actions taken, and resolutions utilizing established policies and procedures.
  • Prepare and submit reports on claim follow-up activities and status updates to management as requested.
• Compliance:
  • Ensure all claims follow-up activities comply with company policies, industry regulations, and legal requirements.
  • Stay updated on changes in insurance policies, regulations, and industry standards.
  • Must meet quantitative production standard of working 75 - 125 claims per week.
  • Attend departmental and company meetings as required.
• Problem Resolution:
  • Identify and report trends which could have an overall negative impact on claim payments such as processing errors, denials, or billing issues.
  • Investigate and resolve discrepancies or issues related to claims processing and payment.
  • Work with other team members and departments ensure proper claim submission.
• Continuous Improvement:
  • Identify and recommend process improvements to enhance the efficiency and effectiveness of the claims follow-up process.
  • Participate in training and development opportunities to stay current with best practices and industry trends.

Qualifications

• A minimum of 5 years' experience as a medical biller or similar role.
• Excellent technical skills including the ability to work in multiple systems simultaneously and learn new systems quickly.
  • EZ-Cap experience preferred.
  • Electronic Data Interchange (EDI) Clearinghouse (Office Ally) experience preferred.
  • Microsoft Suite - Outlook, Teams, Office365, OneNote, OneDrive, SharePoint
  • Sequel Server Management Studio
  • Confluence
  • Azure
• Thorough knowledge of healthcare benefits, network participation, coordination of benefits, referral and authorization requirements, and insurance follow up.
• Working knowledge of CPT Codes, ICD-10 Codes, Modifiers, MUE, LCD, NCD, and CCI edits.
• Must have strong time management skills, be able to multi-task, resolve problems utilizing critical thinking, be detail oriented and highly organized.
• Ability to work in a fast-paced environment while maintaining strict confidentiality.
• Excellent written and verbal communication skills.