Clinical Denials Specialist

JOB SUMMARY: Clinical Denial Representative is responsible to review patient's medical claim when resolving edits for compliance (prior billing) and issues on rejections (rejected by the payor) in the physician side. Clinical Denial Representative must understand and comply with federal and state coding and billing regulations. The Clinical Denial Representative must ensure the confidentiality and privacy of information.Essential Functions:Prepare and process accounts timely and accurately based on client requirements.Review daily account/edit reports from work queues and/or in external billing software and make necessary corrections or resolve edits to allow electronic submission.Resolve edits prior to billing (Compliance) and rejections from the payor (Rejection).Review and take appropriate actions such as but not limited to:Medical Necessity edits,Local Coverage Determination (LCD) and National Coverage Determination (NCD) edits,Medically Unlikely Edits (MUE),Procedure to Procedure (PTP) edits,Diagnosis issues.Enter appropriate account notes into the billing system to clarify actions taken to reconcile claims.Maintain confidentiality of patient records at all times and observe HIPAA compliance.Perform as a team player.Use logic, critical thinking, and reasoning to identify the strengths and weaknesses of alternative solutions to problems.Understand the effects of new information for both current and future problem-solving and decision-making.High attention to detail.Attendance in accordance with company HR and department policies.Other tasks/functions that may be assigned by the company as per business requirements; these may change from time to time to reflect the changing requirements of your position and our business.
#J-18808-Ljbffr