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Denial Specialist

Greene County Health Care
Snow Hill, NC
  • Posted: over a month ago
  • Full-Time
Job Description

Company Overview

Greene County Health Care is a Community Health Center providing comprehensive medical, dental and behavioral health services for members of our communities in Greene, Pitt and Pamlico counties in eastern North Carolina.

Job Summary

The Denials Specialist identifies and works to resolve charge problems to ensure accurate and complete billing. The position reviews third party payer reimbursement denials based on documentation, billing accuracy, medical necessity, coding, modifier and related issues and uses data from these reviews to identify and rectify billing and documentation errors. Actively manages, maintains and communicates denial / appeal activity to appropriate stakeholders and reports suspected or emerging trends related to payer denials to Billing Supervisor.

Responsibilities and Duties

Researches payer denials related to referral, pre-authorization, medical necessity, case management, non-covered services, and billing resulting in denials and delays in payment. Initiates appeals with insurers appropriately.

Submits detailed, customized appeals to payers based on review of medical records and in accordance with Medicare, Medicaid, and third-party guidelines, as well as GCHC’s policies and procedures

Identifies denial patterns and escalates to management as appropriate with sufficient information for additional follow-up, and/or root cause resolution.

Makes recommendations for additions/revisions/deletions to work queues and claims edits to improve efficiency and reduce denials.

Reviews payer communications, identifying risk for loss reimbursement related to medical policies and prior authorization requirements; escalates potential issues to clinical stakeholders, managed care contracting, and leadership as appropriate.

Develops reporting tools that effectively measure and monitor processes throughout the denials management process to support process improvement.

Qualifications and Skills

High School Diploma or equivalent. Associate Degree in related field strongly preferred. Two (2) years of experience in medical practice billing with exposure to working with denials, appeals, insurance collections and related follow-up. Certification as a Medical Coder preferred.

ICD-10 and CPT coding assessment skills

Proficiency with computers, including MS Office, and ability to learn existing and new software systems, as determined by the organization

Advanced verbal and written communication customer service and interpersonal skills are essential.

Must demonstrate a solid understanding and ability to apply contract language in conjunction with a comprehensive understanding of claims denial appeal logic.

Excellent cultural competency and cross-cultural communication skills

Critical thinking, analytical and decision-making skills to solve problems as they arise

Detailed oriented, extremely organized, able to simultaneously work on numerous efforts and demonstrate incredible persistence and determination when dealing with complicated and arduous scenarios with insurance payers

Ability to work independently and cooperatively with the health care team to achieve team objectives

Ability to communicate complex information in a clear, effective manner for a general audience

Ability to remain calm in challenging situations

Ability to communicate effective and assertively while demonstrating compassion and empathy for patient’s individual situations

Ability to work independently

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Greene County Health Care


Snow Hill, NC
28580 USA



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