Denials Management & Prevention Specialist

Baptist Health is the largest healthcare system serving central Alabama, providing comprehensive hospital-based and outpatient services to nearly 60 percent of the residents in Montgomery, Autauga and Elmore counties. To learn more about Baptist Health, visit us at https://www.baptistfirst.org.

The Denial Management Specialist shall be responsible to validate dispute reasons, escalate payment variance trends or issues to management, and generate appeals for denied or underpaid claims. This individual will be expected to be a subject matter expert, to display a certain amount of knowledge and skill, in order to resolve complex and aged accounts with minimal or no assistance necessary. Resolution of accounts may include research of payer and governmental regulations and billing rules, payment research, review of all aspects of the claim such as member information, CPT and diagnosis codes, review of medical records, analysis of managed care contracts and review of the chargemaster. The Specialist will exhaust all appeal efforts based on the dispute reason and according to specific payer guidelines for appeal and dispute resolution. This individual will have in-depth knowledge of payer contracts, billing rules, and administrative guidelines in order to effectively review and analyze denials and underpayments. The Specialist will provide meaningful feedback and recommendations to Managed Care, Revenue Integrity, and Leadership teams regarding any trends or issues and will escalate as needed through payer provider advocates and contracting teams. Additionally, this individual will work collaboratively with other areas in attempts to resolve or minimize ongoing denials and underpayments. The Specialist will accurately and thoroughly document all pertinent collection activity performed. To stay current on regulations, they will participate in continuing education related to payer and governmental policies and guidelines and assist in providing integral information to leadership, managers and trainers to ensure information is disseminated within Patient Financial Services as needed. This position may have additional duties assigned that are within scope of the role.

• High school graduate or equivalent. Associates degree or higher preferred.

• Minimum of at least 3 years experience in a hospital business or medical office environment performing billing and/or collections.

• Advanced knowledge of 1500 and/or UB-04 and Explanation of benefits (EOB) interpretation.

• Intermediate knowledge of CPT and ICD-10 codes.

• Advanced knowledge of insurance billing, collections and insurance terminology.

• Advanced knowledge of reading and understanding managed care contracts and federal and state regulations.

• Maintain professionalism and create a positive experience for both internal and external customers.

• Intermediate PC experience required with knowledge of Excel and Word applications.

• Excellent verbal and written communication skills.

• Strong critical thinking and analytical skills.

• Self-motivated.

• Advanced business letter writing skills to include correct grammar and punctuation.

• Knowledge of reimbursement methodologies for various payer groups.