Denial Specialist

The Denial Specialist performs work related to clinical denial management. The individual is responsible for managing claim denials related to authorization, medical record requests, and coordination of benefits. The individual will actively manage, maintain, and communicate denial/appeal activity to appropriate stakeholders. The individual works independently to plan and organize activities that directly impact reimbursement. This role is key to securing reimbursement and minimizing organizational write offs. The Denial Specialist conducts comprehensive reviews of the claim denial and account, to make determinations of what action to be taken to obtain reimbursement.

Duties and Responsibilities

  • Performs all other duties as assigned. Submit retro-authorizations appeals in accordance with payer requirements in response to authorization denials including but not limited to submitting appeal letter, and results.
  • Submit medical records requested from payer by faxing or portal submission.
  • Review COB information returned from coverage detection, update patient account and resubmit accessions to correct payer.

Job Requirements

  • Education
    • Completed any 4-year college course
  • Experience
    • 6 months BPO experience
    • Strong healthcare background preferably Medical and claims processing
  • Competencies
    • Functional Competencies
      • Basic technical credibility. Deliver basic KPI/s.
      • Basic results orientation and accountability. Checks on own work to ensure all steps are completed accurately, takes action to correct substandard work, and takes pride and ownership in one's work.
      • Basic critical thinking. Identifies sources of data and information and learns where to find the most relevant information for solving problems.
      • Basic problem solving and decision making. Asks appropriate questions to define decisions to be made
      • Basic external awareness. Attends training, webinars, meetings hosted by other departments within ADEC or external organizations.
      • Knowledgeable in working within payer portals.
      • Exceptional accuracy and attention to detail
      • Communicate professionally and timely with external and internal customers.
    • Core Competencies
      • Basic Commitment to the Company’s vision & mission
      • Basic Customer Focus, Excellence, Respect, Teamwork, Integrity, Commitment (CERTIC)
      • Basic Personal awareness, Creates good work and personal habits and rejects bad ones.
      • Basic Social Competence. Listens actively to people's concerns and communicates an understanding of their situation and how they feel.
      • Basic Communicating effectively. Produces and presents appropriate information in a clear, organized, and concise manner, both orally and in writing.
      • Basic Collaboration. Understands the goals of the team and the role that each team member has within the team.

Job Factors

  • Scope of Impact
    • Local
  • Internal Contacts
    • Middle Management
    • Non-Management Staff
  • External Contacts
    • Clients/Business Partners
  • Work Conditions
    • Primarily work from home but subject to change based on business needs
    • Regular shifting schedule
    • Physical Demands (Sitting, Reading, reaching with hands/arms, handling mechanical/electrical equipment, Standing, Talking, Typing, and Listening)



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