Customer Service and Denial Specialist

Competitive Benefits Package including but not limited to:

• Health, Dental, and Vision Insurance
• Life Insurance
• Short-term and Long-term Disability Insurance
• Paid Time Off and Paid Holidays
• 401k Retirement Plan
• Referral Program

• The denial is justified. Document the finding and either change the balance to patient responsibility or refer the claim to the Team Lead or Billing Manager for adjustment/write-off approval.
• An appeal is needed. If so, prepare and submit the appeal.
• An inquiry to the carrier is needed to gather further information (via email, web-based inquiry, or phone call).
• Corrections are needed (insurance policy IDs, prior authorization information, etc.). Make corrections and refile the claim or submit a corrected claim. Work with coding staff when the denial is coding-related, or if any coding (CPT/ICD-10/modifier) changes are needed these must be completed, approved by a certified coder.
• Additional information is needed from the ordering provider’s office, such as insurance information, medical necessity documentation, records, or orders.

• Understand the levels of appeal and the process for each insurance carrier.
• Track timely filing and appeal deadlines and prioritize work accordingly.
• Track and communicate carrier-specific requirements and denial trends to Billing and Coding managers.
• Apply knowledge of billing and claims processing to patient accounts.

• Investigate outstanding claims from the outstanding tickler queue in the billing system. Use insurance carrier websites and phone contact to determine claim status and take appropriate action to resolve issues preventing processing.
• Provide credit balance information to the refund department when necessary.
• Provide payment posters with documentation to post insurance responses when appropriate.

• Assist patients with account inquiries received through inbound telephone calls, written correspondence, emails, and voicemails.
• Process credit card payments through the merchant processing system in accordance with PCI requirements.
• Provide price quotes and billing expectations for upcoming appointments, including good faith estimates for self-pay or uninsured patients where applicable.
• Work with patients to set up reasonable payment plans and help them execute payment methods to ensure timely payments.
• Work with clinic staff to answer billing and balance inquiries in the patient-facing clinics.

• Review electronic claim rejections from payers, research the rejection message, make necessary changes, and rebill the services.
• Review pre-eligibility checks, verify that suggested charges are appropriate, and make necessary changes.
• Review return mail from patients and insurance companies; research and take necessary action based on protocols.
• Review, document, distribute, resolve, and scan miscellaneous correspondence from incoming mail or fax.
• Review health insurance claim forms (CMS-1500/UB-04) and attached information for accuracy.
• Scan and index documentation into the document management system.

• Work with clinic staff answering billing and balance inquiries that take place in the patient-facing clinics.
• Scan and index documentation into the document management system.
• Work as a contributing and collaborative team member with others in the billing office to complete billing processes timely, effectively, and efficiently.
• Attend all staff meetings and education workshops/training and notify Billing Manager of any questions/training needed to perform the role.
• Report any issues relating to staffing, morale, work methods, and procedures to the Billing Manager in a timely manner.