Insurance Denials and Appeals Clerk

Summary

The Insurance Denial & Appeals Clerk is responsible for maintaining current patient accounts. Handles insurance claim denials, rejections and resubmission of claims. The position reviews third party payer reimbursement denials based on the following: documentation, billing accuracy, medical necessity, coding, modifier and related issues. Uses data from these reviews to identify and rectify billing and documentation errors, maintain and communicate denial / appeal activity to appropriate staff and report suspected or emerging trends related to payer denials to Billing Manager.

• High school graduate or equivalent
• 2 years’ experience preferred in managing insurance appeals and denials
• Extensive knowledge of third party billing and payment methodologies required
• Knowledge of CPT, ICD-10-CM, HCPCS, and modifiers necessary
• Excellent computer skills including Excel, Word, and Internet use
• Detail oriented with above average organizational skills
• Plans and prioritizes to meet deadlines
• Good oral and written communication skills
• Ability to deal professionally, courteously and efficiently with the public and all levels of the organization
• Ability to handle multiple projects simultaneously
• Ability to operate computer, copier, fax
• Proficient in practice management system and Microsoft Office software applications
• Knowledge of HIPAA guidelines and requirements.

• Review and analyze claim denials in order to perform the appropriate appeals necessary for reimbursement.
• Receives denied claims and researches appropriate appeal steps.
• Communicates directly with the payer, resubmits denied claims, underpaid claims and claims that are inaccurately processed.
• Tracks and documents all denials by payer, visit type and denial category.
• Identifies, documents, and communicates trends in recurring denials and recommends process improvements or system edits to eliminate future denials.
• Works with the payers to understand specific reasons for denials and preventable measures available to prohibit future denials.
• Process patient refunds in a timely manner, submitting refund requests at the time of insurance payment/EOB receipt.
• Communicate with multiple levels in the organization (e.g, managers, physicians, clinical and support staff).
• Maintain confidentiality of sensitive information
• Work closely with the billing manager and billing staff to identify and resolve any denials issues related to provider credentialing.
• Work special projects set by billing manager.
• Other duties as assigned.
• Cross trained to provide billing department coverage in any task needed to meet end of the month deadlines.
• Responsible for staying current with the rules and updates or changes in state and federal regulations.
• Continually search for ways to improve the accounts receivable process, striving for efficiency in daily operations.
• All Health Center staff members have emergency and disaster response responsibilities. Participates in all safety programs which may include assignment to an emergency response team.

• Paid Time Off
• 10 Company holidays
• 1- 8-hour Personal holiday
• 401(k) retirement plan- employer matches up to 5%
• Bereavement Leave
• Continuing Education
• Employee Assistance Plan
• Student Loan Forgiveness-if applicable
• Medical, Dental, Vision – Aetna
• Basic Life ($35k)/AD&D – 100% paid for by the employer
• Employee Assistance Plan (EAP) – 100% paid for by the employer
• Additional benefits available at employee expense:
  • Additional Voluntary Life Insurance
  • Short-Term Disability (STD)
  • Long-Term Disability (LTD)
  • Accident Insurance
  • Critical Illness Insurance
  • Hospital