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2025/03/12) Denial Resolution Specialist II

1 week ago

Worcester, Western Cape, South Africa Hahhh Full time
Denial Resolution Specialist II

Apply: Remote Caregivers (Primarily Remote) - Worcester, MA - Full time - Posted Yesterday - Job Requisition ID R

Exemption Status: Non-Exempt

Schedule Details: Monday through Friday

Scheduled Hours: 8:00-4:30

Shift: 1 - Day Shift, 8 Hours (United States of America)

Hours: 40

Cost Center: Denials

Union: SHARE (State Healthcare and Research Employees)

This position may have a signing bonus available; a member of the Recruitment Team will confirm eligibility during the interview process.

Everyone Is a Caregiver

At UMass Memorial Health, everyone is a caregiver – regardless of their title or responsibilities. Exceptional patient care, academic excellence, and leading-edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve.

I. Major Responsibilities:

1. Triages denial root cause and executes appropriate next steps.
2. Identifies trends and participates in interdepartmental resolution strategies to reduce and eliminate future denials. Researches complex denials as assigned.
3. Trains staff on payer websites, providing basic guidance and instruction on website navigation.
4. Uses assigned work queues and prioritization standards and guidelines to perform denial resolution follow up.
5. Resolves accounts denials with high dollar balances (> $100,000) recognizing the potential complexity and the need for rapid resolution.
6. Uses reference material to troubleshoot payer issues and increase understanding of denial resolution techniques.
7. Analyzes and researches the denial reasons for each assigned denial code.
8. Participates in payer and internal audits. Maintains appropriate documentation related to original audit findings.
9. Corrects and updates claim information in the Medicare FISS system.
10. Completes appropriate actions needed for an effective appeal.
11. Corresponds with third party payers, hospital departments, and patients to obtain information required for denial resolution.
12. Documents all actions taken during the denial resolution process clearly.
13. Meets established quality and productivity standards.
14. Maintains a collaborative, team relationship with peers and colleagues.

II. Position Qualifications:

License/Certification/Education:
Required:
1. A minimum of a High School diploma.

Experience/Skills:
Required:
1. Four or more years of experience in health care billing functions.
2. Previous health care billing experience.
3. Proven track record of successful performance and goal achievement.
4. Experience in denial resolution process.
5. Advanced knowledge of claim form content and claim submission requirements.
6. Ability to communicate verbally and clearly document all actions taken during resolution process.

III. Physical Demands and Environmental Conditions:

Work is considered sedentary. Position requires work indoors in a normal office environment.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

UMass Memorial Health recognizes the power of a diverse community and encourages applications from individuals with varied experiences, perspectives, and backgrounds.

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