Denial Specialist
- Edgewater Health
- Gary, Indiana
- 14 days ago
- Full Time
Job Summary
Job Description
Job Location: Corporate Headquarters - Gary, IN
Position Type: Full Time
Education Level: High School
Job Shift: Day
Job Category: Finance
Description
GENERAL DESCRIPTION:
The Prior Authorization/Denial Specialist is expected to demonstrate an attitude of teamwork by creating a relationship with patient accounts, health information services, finance, clinical managers as well as administration.The position should maintain a constancy of purpose and continuous education of payer billing compliance and reimbursement regulations, especially for Indiana Medicaid, Clinic Option and Medicaid Rehabilitation Option.
DUTIES AND RESPONSIBILITIES:
Responsibilities include daily and/or weekly review of payer denials. This requires logging all denial reasons, patient name, account number, program, service activity code and clinician. In addition, a constant review of government and payer bulletins and memorandums that are specific to billing and coding changes specific to behavioral health and addictions is required.
DIRECT DUTIES:
- Constant review of all remittance advice and explanation of benefits for zero pays and denials.
- Log all denials by reason code.
- Address denial issues with management.
- Monitor billing and medical policy notices from all payers.
- Solicit assistance from clinical, health information and/or quality personnel to resolve denial issues.
- Process and submit appeals when appropriate to all payers.
- Ensure compliance with federal and state rules and regulations.
- Provide education to clinicians, business office staff regarding Medicare, Medicaid and commercial reasons for denials.
- Cross training to serve as a back up in the finance department when needed.
- Promotes effective working relationship and work effectively as part of the department team to facilitate departmental goals and objectives.
- Performs other duties as assigned.
ADMINISTRATIVE:
- Maintain clinical and management records in accordance with assigned Services Programs.
- Maintain 100% UM/UR compliance.
- Other responsibilities and tasks as may from time to time be assigned.
GENERAL
- Conduct all professional activity in an ethical manner.
- Conform to all applicable policies and procedures.
- In conjunction with other staff assist in identifying and eliminating any situation which jeopardizes the health and/or safety of clients, staff, or others who come in contact with community mental health center operations.
- Utilize literature, workshops and other training aids to continually improve clinical and administrative skills.
- In conjunction with supervisor, complete and implement Individual Professional Development Plan.
- Assist in assuring Edgewater Health compliance with all related licensing and accreditation requirements.
SUPERVISED BY:
Accounts Receivable Director
WORKERS SUPERVISED:
None
Qualifications
MINIMUM QUALIFICATIONS:
- Education – Associate degree from an accredited college or university preferred. Completion of formal bookkeeping or accounting course work preferred.
- Other – Experience with Medicare, Medicaid and Commercial insurance billing required.
- Have knowledge of the healthcare industry specific to Center for Medicare and Medicaid Services (CMS) rules and regulations for behavioral health and addictions.
- Prefer coding experience but not required.
Job Summary
Benefit Insights
Edgewater Health
Job ID: 469871233
Originally Posted on: 3/19/2025