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Medical Claims Denial Specialist

Company: Lags Spine and Sportcare Medical Centers Inc
Location: Reno
Posted on: May 22, 2020

Job Description:

Under the supervision of the Manager, the Medical Claims Denial Specialist performs advanced level work related to claims denial or underpayment management. The individual is responsible for managing claim denials by conducting a comprehensive review of insurance ERA/EOB denial CAS and Remark Codes, clinical documentation, medical necessity guidelines, eligibility and authorization, ICD-10 Coding, CPT and HCPCS Coding. The Claims Denial Specialist will, based on their analysis, follow each payer specific guidelines for resubmitting corrected claims, filing first level provider dispute resolutions, first level appeals, or other appropriate rework of the claims reviewed. Core Responsibilities:

  • Research payer denials related to referrals, prior authorization, medical necessity, case management, non-covered services, and other billing issues and delays in payment.
  • Initiate appeals with payers appropriately
  • Submit detailed, customized appeals to payers based on review of medical records and in accordance with Medicare, Medi-Cal, Medicaid, and other Payer policies and procedures
  • Communicate with Manager/Supervisor when Peer-to-Peer reviews may be requested or require and communicate thoroughly and accurately with payers and Peer Review organizations to resolve denials
  • Identify denial patterns and escalate to management as appropriate with sufficient information for additional follow-up, and/or root cause resolution
  • Make recommendations for additions/revisions/deletions to claim edits to improve efficiency and reduce denials
  • Review payer communications, identifying risk for loss of reimbursement related to medical policies and prior authorization requirements; escalates potential issues to Manager/Supervisor as appropriate
  • Assist with complex, specialized billing and follow-up workflows including but not limited to:
  • ASC, OR and Clinic Procedure billing and reconciliation
  • RAC correspondence and appeal processing, as well as other audit reviews
  • Advanced or Specialized procedures or services requiring extensive communication with other departments
  • Other special projects as assigned We offer a comprehensive benefit package that includes medical, dental, vision, 401k, 11 paid holidays, PTO plan, opportunities for career growth and much more.LAGS Medical Centers is a pain management group operating throughout California, Oregon, Washington, Florida & Nevada. Since 2000, the LAGS alternative approach to pain treatments has returned patients to a healthy, active lifestyle: restoring function by minimizing pain..

    • High school degree or equivalent
    • Minimum of 2 years Medical Billing or related experience
    • Must be familiar with authorizations, ICD-10 Coding, CPT and HCPCS Coding
    • Must have high attention to detail PI120345628

Keywords: Lags Spine and Sportcare Medical Centers Inc, Reno , Medical Claims Denial Specialist, Healthcare , Reno, Nevada

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