• Manage the day-to-day activities of the staff supervised on site or remotely for a client hospital. • Monitor the status of outstanding patient accounts, identifying and resolving billing errors and claim denials. • Conduct weekly team meetings driving revenue cycle performance needs and continued training, maintain and track SOP’s and process improvement processes. • Implement strategies to improve collection rates and reduce outstanding accounts receivable. • Follow up on complex payer trends, communicate with Management the volume and specific issue along with researched payer specific guidelines.

• Contact insurance carriers on a daily basis to follow up on/collect past due amounts on outstanding medical claims regarding denials or benefit changes. • Maintain an accurate, up to date aging of assigned accounts including AR analysis and follow up. • Keep educated on billing and medical policies for all payers. • Have a working knowledge of In and Out of Network reimbursement processes/methodologies. • Create and follow up on appeals needed to protest denials or incorrect payments. • Review complex denials/tasks assigned by the payment posting team and resolve accordingly including reviewing refund requests, disputes and appeal as necessary. • Work across all RCM departments to get issues related to claims payment resolved. • Uphold and ensure compliance and attention to all company policies and procedures as well as the overall mission and values of the organization. • Work with AR Supervisor to review/resolve open accounts as assigned. • Perform other duties as assigned.

Role Description The goal of the Clinical Denial Specialist is to successfully manage claim denials related to referral, authorizations, notifications, non-coverage, medical necessity, and other clinically related denials, as assigned. The specialist will review claims and make recommendations for claim resubmission, retro authorization, written appeal or if no action is needed. The Clinical Denial Specialist will write / submit professionally written appeals including arguments based on the clinical documentation, payer medical policies and contract language. The appeals will be submitted timely and tracked for outcome and trends. Qualifications - Associates Degree in a business or healthcare related field. - Registered Nurse (RN) Certification with experience in care management, utilization review, prior authorization and appeals. - Electronic Health Record Experience with various platforms (Epic, Cerner, Meditech). - Knowledge of all insurance payers preferred. - Proficient PC knowledge and the ability to type 30-40 wpm. - Professional written and verbal communication skills. - Capacity to prioritize multiple tasks in a busy work environment. - Organization and time management skills. - Capability to present oneself in a courteous and professional manner at all times. - Ability to stay on task with little or no supervision. Requirements - Research assigned payer denials (referral, authorization, notification, medical necessity and non-covered services). - Independently write / submit professional appeal letters in accordance with client and payer policies. - Prepares reports for management review and identifies trends. - Reviews and understands utilization review and coverage guidelines for multiple payers. - Identify process improvement opportunities. - Monitor denial and appeal outcomes and trends, and report findings to management. - Ensure all denial management activities comply with federal, state and payer regulations, including HIPAA requirements. Benefits - Medical - Vision - Dental - 401K - Paid Time Off

• Submits timely, accurate invoices to payer for products and services provided. • Understands the terms and fee schedule for all contracts for which invoices are submitted. • Correctly determines quantities and prices for drugs billed. • Verifies that the services and products are correctly authorized and that required documentation is on file. • Ensures that invoices are submitted for services and products that are properly ordered and confirmed as provided. • Evaluates payments received for correctness and applies payments accurately to the system. • Verifies that payments received are correct according to the fee schedule. • Applies the payment correctly to the patient account. • Ensures that secondary bills and patient invoices are mailed within 48 hours of receipt of payment. • Notifies the Reimbursement Manager if there are overpayments and/or duplicate payments for the same service. • Transfers payments belonging to other offices within 48 hours of receipt. • Follows up on invoices submitted to ensure prompt and timely payment. • Calls to verify that claims submitted were received and are in processing. • Sends letters to the patient or responsible party when their insurance carrier fails to make payment reasonable time frame. • Generates and mails statements and collections letters. • Follows-up on all denials within 48 hours of receipt. • Ensures compliance with policies and guidelines outlined in the contract terms and fee schedule. • Follows HIPPA guidelines when accessing and sharing patient information to maintain patient and business confidentiality.