The Appeals and Denials Specialist will be responsible for managing and resolving claim denials and appeals efficiently and effectively. This role requires a deep understanding of industry regulations, strong analytical skills, and the ability to communicate clearly and professionally with payers.
- Review denied or underpaid medical claims for accuracy and compliance with payer guidelines
- Draft and submit written appeals to insurance companies or other payers, citing supporting medical documentation, coding references, and policy guidelines
- Monitor the status of submitted appeals and follow up to ensure timely resolution
- Analyze explanation of benefits (EOB's) and remittance advice (RAs) to identify denial trends or coding issues
- Collaborate with billing teams to correct errors and resubmit claims as needed
- Maintain detailed records of appeal activities and outcomes in the patient account management system
- Act as liaison between healthcare providers, patients, and insurance companies to resolve payment disputes
- Communicate effectively with physicians and other healthcare professionals to obtain additional documentation or clarification needed for appeals
- Participate in team meetings and share insights on payer-specific denial trends or policy changes
- Stay updated on changes in medical billing codes, payer policies, and reimbursement guidelines
- Escalates payer denials trends or claims issues to the PFS Leadership Team to address with the payer
- Identifies trends, system issues, and potential process improvements to avoid future delays and denials
- Fosters an inclusive and engaged environment through teamwork and collaboration
- Safety And Performance Improvement
- Demonstrates accountability and commitment to quality work
- Participates actively in process improvement and adoption of standard work
- Stewardship
- Demonstrates responsible use of LRH's resources, including people, finances, equipment, and facilities
- Knows and adheres to organizational and department policies and procedures
- Demonstrates accountability and commitment to quality work
- Participates actively in process improvement and adoption of standard work
- Actively participates in team development, achieving dashboards, and in accomplishing department goals and objectives
- Responsible for all aspects of follow-up and collections on accounts
- This includes making outbound calls to payers and accessing payer websites
- Research denials and works with other departments such as Collections, Billing and UR
- Submits the insurance reconsideration/appeals with supporting documentation promptly and follows up with insurance to ensure receipt and processing
- Follows insurance payer claims and appeals' timely filing guidelines
- Responsible for working correspondence timely and efficient manner (including EOBs, RA’s, denial letters)
- Knowledge of HIPAA guidelines
Experience:
- A minimum of 1 to 2 years’ experience in appeals and denials, preferably in a healthcare setting.
- Previous appeals and denials experience preferred.
- Substance Abuse experience preferred
Education:
- Preferred some college or related vocational training.
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Health insurance
- Life insurance
- Paid time off
- Professional development assistance
- Tuition reimbursement
- Vision insurance
Schedule:
- 8-hour shift
- Monday to Friday
Ability to commute/relocate:
- Boca Raton, FL: Reliably commute or planning to relocate before starting work (Required)
Work Location: In person
WORK ENVIROMENT & PHYSICAL REQUIREMENTS
- Work is performed in an office setting.
- Prolonged periods sitting at a desk and working on a computer.
- Must be able to lift up to 15 pounds at a time.
- Physical demands of position: sitting, standing, walking, typing, phone communication, face to face conversation.
Job Type: Full-time
Behavioral and mental health experience is preferred, but not limited to Inpatient, Outpatient, mental health, and substance abuse billing(at least 3 years)
Ability to prioritize tasks properly
Organized and able to multitask
Excellent verbal and written communication skills
Proficient in Microsoft Office Suite (Excel, Word, PowerPoint, Outlook)
Job Type: Full-time
Work Location: In person
