Denial & Reconsiderations Specialist

Larkin Health System is an integrated healthcare delivery system accredited by the Joint Commission with locations in South Miami, Hialeah and Hollywood, Florida. Our network of acute care hospitals provide a complete continuum of healthcare services, including a full range of inpatient and outpatient services, and home health agencies in Miami-Dade and Broward County. We are heavily invested in training the next generation of health professionals, which is the core of our mission: to provide access to compassionate care of the highest quality in an educational environment.

GENERAL JOB DESCRIPTION

Under the direction of the Business Office Director, the Denials and Reconsideration Specialist is responsible for administrative denial management. Conducts a comprehensive review of the denied account, and then will write compelling arguments based on the documentation and the policies of the payer and submit the appeal in a timely manner.

DUTIES AND RESPONSIBILITIES

Prepare appeal and/or reconsideration letters for administrative denials by accessing specific payer appeal forms, submitting appropriate medical documentation, and tracking appeal resolution. Follow up on submitted appeals through payer portals or phone calls to payer. Identify denial trends, root cause and A/R impact. Seek resolution to problematic accounts and payment discrepancies. Follows account to timely resolution to include appropriate financial adjustment. Ensures compliance with current state, federal and CMS regulations. Maintains working knowledge of applicable insurance carrier s timely filing deadlines, claims submissions processes, and appeals processes. Preforms related duties as required.

QUALIFICATIONS FOR THE JOB

Education:

High School diploma of equivalent (additional certifications or education in medical billing/coding preferred)

Experience :

Five or more year s denials management and appeals documentation experience. Prior experience in healthcare claims processing and proficiency with medical billing and remittance forms.

Other:

Expert knowledge in Medicare, Medicaid, Managed Care and Commercial hospital billing and collections. Proficiency in medical terminology, coding systems and medical billing procedures. Demonstrate ability to research and resolve difficult claim denials and documentation issues.