Denial Management SpecialistWork remotely while using your denial management expertise to make a direct impact on healthcare operations.Work Style: Remote Location Requirement: Must reside in an approved state (FL, GA, PA, NC, SC, TN, or TX) FTE: Full-Time (1.0 FTE)Responsible for maintaining low denial rates and optimizing reimbursement across the enterprise by ensuring high coding standards and effective denial management practices. Leads and supports initiatives to improve coding accuracy, reimbursement outcomes, and appeal turnaround times.Performs in-depth analysis of denial trends, including Epic system edits, coding validation, Charge Description Master (CDM) processes, authorization trends, and payer denials. Identifies opportunities for performance improvement and implements strategies to enhance revenue cycle outcomes.Educates departments on appropriate charging, billing, and coding practices to ensure regulatory compliance.
Collaborates with Managed Care, Compliance, and operational teams to resolve complex issues with departments and payers, driving sustainable improvements in reimbursement and denial prevention.ResponsibilitiesKey Responsibilities:Manages clinical denials from assigned work queues, including claim resubmissions, authorization verification, payer reprocessing, reconsiderations, and appealsPartners closely with Managed Care and payers to reduce denials and improve reimbursement outcomesAnalyzes denial trends and develops recommendations to improve coding accuracy and documentation practicesMeets established productivity and accuracy standards, including reviewing approximately 30 accounts per day with a 98% accuracy rateApplies coding guidelines (NCCI, ICD-10, CPT, HCPCS, CMS) to accurately review, code, and correct accountsCollaborates with department managers to track, report, and resolve denials, including participating in audits and compliance reviewsIdentifies root causes of denials, tracks trends, and escalates findings to leadership for follow-up and process improvementWorks across multiple payer work queues, including Medicare, Medicaid, government, and commercial payersResearch denials related to authorization, medical necessity, non-covered services, coding, and billing issues, ensuring timely resolution and appeal submissionPrepares and submits detailed, well-supported reconsiderations and appeals based on medical record review and payer requirementsMonitors payer communications and policy updates to identify risks impacting reimbursement and authorization requirementsReviews and corrects coding, including modifier usage, diagnosis sequencing, and compliance with coding guidelinesReviews and adjusts charges as needed based on documentation, billing, and regulatory standardsEducates departments on denial prevention strategies, including improvements in coding, charging, and authorization processesQualificationsMinimum Qualifications:High School Diploma or GED requiredOne of the following coding certifications required: CPC, COC, RHIT, RHIA, or CCS1–2 years of coding experience, along with 1–2 years of denial management and/or insurance-related experience