DENIAL MANAGEMENT SPECIALIST at Jamestown Regional Medical Center

Jamestown, North Dakota, United States -

Full Time

Start Date

Immediate

Expiry Date

21 Jan, 26

Salary

0.0

Posted On

23 Oct, 25

Experience

0 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Denial Management, Insurance Claims, Medical Records Review, Appeals Process, Analytical Skills, Communication Skills, Organizational Skills, Problem Solving, Team Collaboration, Attention to Detail, Patient Interaction, Documentation, Compliance, Time Management, Clerical Skills, Computer Skills

Industry

Hospitals and Health Care

Description

Description STATEMENT OF PURPOSE Receives, reviews, investigates and refers denials, grievances, and appeals. Gather information on each claim through medical records review, notes, invoices, etc. and prepares appeals summaries while ensuring compliance with organization standards and the regulatory requirements. This is a full time position working 72 hours per two week pay period. Days of work are Monday - Friday from 8:00am - 4:30pm or 4 10 hours shifts with no nights, weekends or holidays. JOB FUNCTIONS Reviews, interprets, and analyzes denials of insurance claims to determine the cause of the denial such as medical policy, missing authorization, coding issues, etc. Facility insurance enrollment-work with insurance companies to provide them with the requested accurately filled out forms and documents to maintain JRMC’s good standing to bill those insurances. Work must be done within timeframes required by insurance companies. Works with billers, prior authorization specialists, coders, and providers to appeal denials. Respond to all levels of denials by submitting appeal letters and required documentation to insurance companies within the designated payer timeframes. Review case history, payer history, and state requirements to determine appeal strategy. Obtain patient and/or physician consent and medical records when required by the insurance plan or state. Gather and fill out special appeal or review forms. Coordinate phone hearings with the insurance company, patient, and physician. Comply with all 1st, 2nd, 3rd, and External Level Appeal processes. Meet appeal filing deadlines by completing assigned worklist tasks in a timely manner and/or reporting to management when assistance is require to complete the tasks. Report all insurance company or state requirements and denial trends to the PFS Manager and Reimbursement Specialist. Participate in team and appeal meetings by sharing the details of cases worked. Assists with payment posting, resolves clearing house account errors, posting errors, finds missing remits, helps set up website access for payments. Backup support to Prior Authorization/ Insurance Verification team. Interacts with patients in the adolescent, adult, and geriatric age groups while performing duties. Act as backup on answering incoming telephone calls as needed. Insurance Biller duties as needed. Performs other related duties as assigned or requested. Requirements QUALIFICATIONS/REQUIREMENTS FOR THIS POSITION: (DENIALS ANALYST) PREPARATION AND TRAINING - High school level of education preferred; computer and/or secretarial skills. WORK EXPERIENCE - One year clerical experience with computer knowledge with more than three months of progressively more responsible experience required; three months on-the-job training. ATTENDANCE - Punctual and regular attendance is an essential responsibility of each employee at JRMC. Employee are expected to report to work as scheduled, on time and prepared to start working. Employees are also expected to remain at work for their entire work schedule. ANALYTICAL ABILITY - Gather and interpret data in unusual situations and solving complex problems; good organizational skills. INDEPENDENT JUDGEMENT - Independent judgment is often required; moderate consequences of errors of judgment. CONTACTS WITH OTHERS - Social sensitivity and effective communication is required with public contact and co-workers; compliance to behavior standards is required. SUPERVISING THE WORK OF OTHERS - Manages own work. RESPONSIBILITY FOR WELFARE OF OTHERS - Infrequently provides for the physical well-being of the patient which may result in negligible consequences. MENTAL/VISUAL EFFORT - Must be able to concentrate amid distractions; think clearly under pressure; work regularly requires high level of mental/visual effort. Must be able to speak and write the English language in an understandable manner. Must be in good general health and demonstrate emotional stability. Visual acuity necessary for performing routine procedures. WORKING CONDITIONS - Works in well-lit office with some inconvenience caused by crowded work area; area subject to temperature discomforts and noise. May be required/requested to work on shifts other than the one for which hired. Works at multiple work stations utilizing a variety of equipment. Participates in and complies with JRMC Safety Management Program. Maintains knowledge of and observes Standard Precautions. Practices aseptic techniques whenever appropriate. OSHA Job Classification: This position is defined as a Category II: Employee does not have exposure to bloodborne pathogens. PHYSCIAL AND SENSORY EFFORT - Must be able to occasionally accomplish movement of computer paper and forms that are a maximum of 50 pounds. Occasional reaching, stooping, bending, kneeling, and crouching. Constant sitting is required to perform the major responsibilities of this job. PROMOTION - No formal line of promotion. EMPLOYEE REQUIREMENTS Visual Observation - Continuously Standing - Rarely Walking - Occasionally Sitting - Continuously Hands and Finger Dexterity - Frequently Reaching with Hands and Arms - Frequently Climbing - Rarely Stooping/Kneeling/Crouching/Crawling - Rarely Hearing/Listening - Continuously Tasting or Smelling - Rarely Working Inside - Continuously Working Outside - Rarely Working in Extreme Heat - Rarely Working in Extreme Cold - Rarely Working with Hazardous Materials - Rarely Noise - Rarely Working in Dirt/Dust - Rarely Driving - Never Lifting / Carrying / Pushing / Pulling: - Up to 10 pounds - Rarely Up to 25 pounds - Rarely Up to 50 pounds - Never Up to 75 pounds - Never Up to 100 pounds - Never Over 100 pounds - Never

Responsibilities

The Denial Management Specialist reviews, investigates, and appeals insurance claim denials while ensuring compliance with organizational standards. This role involves gathering information from medical records and coordinating with various stakeholders to resolve issues.