Denial Specialist

  • Edgewater Health
  • Gary, Indiana
  • 14 days ago
  • Full Time

Job Summary


Employment Type
Full Time

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


Employment Type
Full Time

Benefit Insights


Health Insurance
Vacation Leave
Sick Leave
Holiday Pay
Life Insurance
Dental Insurance
Vision Insurance
Short-Term Disability

Edgewater Health

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Job ID: 469871233

Originally Posted on: 3/19/2025