Denial Specialist

Job Details

Description

Working Hours: 8:00am - 4:30pm (Monday - Friday)

Occasional extended hours may be required to meet business needs.

Training Hours: 8:00am - 4:30pm (Monday - Friday)

Occasional extended hours may be required to meet business needs.

Company Mission: To be the best provider of comprehensive and innovative clinical laboratory services for the prevention, diagnosis and treatment of complex chronic disease.

Company Vision: The Genova Diagnostics team will improve the lives and well-being of patients by bringing insights to the complexity of health.

Position Summary

The Denial Specialist is responsible for working third party A/R and denials to ensure appropriate payment for Genova’s claims and timely resolution of third party accounts receivable according to Genova policy. Completes denial follow up and no response research with insurance carriers, patients, and clients to ensure claims are processed and to obtain adjudication information. He/she re-submits claims and appeals as necessary to ensure appropriate and timely reimbursement. The Denial Specialist is responsible for maintaining the 48 hour turn-around time requirement for the daily posting of all payment/adjustment categories including check, EFT, and Zero payment, Patients, Consumers, EOB’s and remittances manually and electronically. Interpretation of the Explanation of Benefits (EOB) and claim adjudication will be required in order to post remittances at the CPT code and denial code level. The position is responsible for the accurate posting of payments and adjustments to the correct invoices. This position supports billing processes and other A/R processes as necessary to ensure excellent cash collections and DSO performance.

Essential Duties And Responsibilities

Responsibilities include but are not limited to the following:

Technical

• Maintains full awareness of compliance issues in relation to any insurance contracts, and other insurance regulatory issues. Must report any concerns with applicable government regulation, compliance issues to the Office of Quality.
• Works patient accounts to ensure appropriate adjudication and payment of claims. Processes re-bills, appeals, and processes adjudication information.
• Makes corrections to patient accounts in billing system to obtain reimbursement for claims.
• Works in clearinghouse system to correct claims and obtain information required to obtain reimbursement for claims.
• Uses web resources, imaging system, A/R system, clearing house, and other Genova systems in the course of working A/R and denials to obtain information required for appropriate reimbursement.
• Work denials from third party payers. This includes submitting requested lab results, corresponding with practitioners to obtain medical records and resubmitting claims as needed.
• Prepare and submit any insurance secondary billing when appropriate.
• Interpretation and posting of all 3rd party insurance (including Medicare and Medicaid) EOB’s and remittances, manually and electronically to both SCC and to the reimbursement database (DAD). Including the reconciling of daily Cash batches back to the deposit totals.
• Processes patient accounts to ensure appropriate adjudication, payment, and posting of adjustments/payments.
• Forwarding EOB and Insurance remittances to Denial Management Team for review and further action via correspondence coding.
• Communicating trends and problems to Supervisor.
• Handling NSF (not sufficient funds) check returns by re-depositing and re-posting payments.
• Researching credit card “charge backs”, fax responses and re-post payments if needed.
• Maintaining EOB and deposit records and files.
• Posting payment transfer requests to move and correct payment posting.
• Daily, create and complete all Response Posting safety net reports.
• Other duties as necessary and delegated by Denial Management/Response Posting Supervisor or Group Leader.

Other

• Regularly contacts insurance carriers through telephone calls to work third party accounts receivable, also contacts client offices and patients in the course of resolving third party accounts receivable.
• Processes, follows up, takes actions in a timely manner based on working denial and aging reports.
• Provides excellent customer service to patients, clients and payers.
• Assist the cash posting team with EOB and remittance informational needs and questions, including payment and adjustment interpretation.
• Other duties as necessary and delegated by Denial Management/Response Posting Supervisor and Genova Management.
• Works closely with all ARBO Teams, insurance payers and other Genova customers.

Supervisory Responsibilities

This job has no direct supervisory responsibilities but does require close communication with all ARBO teams.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Candidates must have the following skills and attributes: experience in insurance billing and knowledge of CPT and ICD-10 coding; knowledge of medical insurance reimbursement methods and processes; complete understanding of medical necessity and non-covered service; data entry and basic accounting skills; strong analytical skills for problem solving; process oriented problem solver; high level of commitment; and a strong desire for professionalism, quality, and achievement. He/she must be able to communicate effectively with an emphasis on customer service. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education And/or Experience

This position requires a high school education. Associates degree in business preferred, relevant work experience will be substitutable for the appropriate candidate. Candidates must have one year of experience in cashiering and refunds application within a Medical Office setting. One year knowledge and experience with posting 3rd party payments and adjustments, manually and electronically. One year knowledge and experience with Insurance EOB interpretation and medical claim reimbursement methods and allowances. Candidates must have a minimum of one year of practical experience in insurance billing and follow-up.

Computer Skills

To perform this job successfully candidates should be comfortable with standard Windows-based software packages of Word and Excel.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit for extended periods of time; use hands to finger, handle, or feel; reach with hands and arms; talk; hear. The employee is occasionally required to stand and walk. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision and ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.