Revenue Cycle Denial Representative

Role Description: We are seeking a detail-oriented and analytical Revenue Cycle Denial Representative to join our team. This role is responsible for managing hospital claim denials, identifying root causes, and working with payer's and internal teams to resolve and prevent future denials. The ideal candidate will have experience in hospital revenue cycle operations, insurance claim processing, and a strong understanding of payer policies and regulations.

Roles & Responsibilities

• Review and analyze denied hospital claims to determine root causes and appropriate resolution strategies.
• Knowledgeable resolution in top denials such as but not limited to No Authorization, Timely Filing, Coordination of Benefits, Additional Documentation Request, etc.
• Work with payers, including Medicare, Medicaid, and Commercial insurers, to appeal and resolve denied claims.
• Identify trends in denials and collaborate with internal departments such as coding and billing to implement corrective actions.
• Prepare and submit appeals and reconsideration requests in compliance with payer guidelines and deadlines.
• Maintain thorough documentation of denial reasons, appeal actions, and resolutions in the billing system.
• Monitor payer policies and regulatory changes to ensure compliance and proactive denial prevention.
• Communicate effectively with insurance representatives and internal leaders to expedite resolution and improve processes.
• Assist in developing the best practices and training materials for denial management and prevention.
• Meet departmental productivity and quality standards to optimize reimbursement and minimize revenue loss.

Analize account history previous actions prior to taking next action step to resolve the claim

Utilized resources provided by the client to promote accuracy of work events to resolve claims.

• Understand when claim corrections and rebilling are applicable

Escalate claims with payers for resolution on inaccuracy and delayed processing of claims.

Meet specified goals and objectives assigned by management and/or Client.

• Ensure compliance with federal, state, and payer regulations, as well as hospital policies.

Always maintain confidentiality of account information.

Adhere to the prescribed policies and procedures as outlined in the Employee Handbook and the Employee Code of Conduct.

Maintain awareness of and actively participate in the Corporate Compliance Program.

Maintain a confidential and orderly remote work area.

Assist with other projects as assigned by management