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Denial Management Specialist


This is a Full-time position in Anaheim, CA posted November 19, 2021.

Revenue Recovery Analyst Temp Opportunity Available!!

This Jobot Job is hosted by: Kristin Ursua
Are you a fit? Easy Apply now by clicking the “Apply Now” button and sending us your resume.
Salary: $45,000 – $65,000 per year

A bit about us:

We are a Healthcare organization around for over 100 years providing people with help with their healthcare needs. We truly care about everyone who comes through our doors and we do all we can to assist the with their health issues, questions or concerns. We consist of 159 medical and non-medical affiliates, which operate over 600 health clinics in the U.S. We partner with organizations in 12 countries globally. The organization directly provides a variety of reproductive health services and sexual education, as well as contributing to research in reproductive technology.

Why join us?


  • Welcoming: Anticipates customer requirements and gives high priority to customer satisfaction and service. Handles problems quickly and efficiently. Maintains a pleasant, positive and professional approach. Embraces opportunities to help team members, stakeholders, and other departments.
  • Ethical: Deals with others in a sincere and honest manner. Accepts responsibility for actions. Supports company values and follows the Standards of Conduct.
  • Confidential: Respects the information shared by our patients, employees, and vendors and maintains appropriate confidentiality. Follows all policies and laws that protect private & privileged information.
  • Accessible: Is available and approachable to others, open-minded, fair and non-defensive. Appreciates constructive feedback and is a team player. Demonstrates good listening skills.
  • Respectful: Values diversity and treats everyone with dignity and courtesy. Dependable and courteous of other people’s time and commitments.
  • Empathetic: Demonstrates interest and understanding in other people’s feelings, attitudes and reasoning. Maintains an open and non-judgmental demeanor that is patient, flexible, and understanding.

Job Details

The Denial Management Specialist identifies, collects and determines root causes of underpaid claims by auditing payor performance and analyzing actual payments of payors to ensure contract compliance which is operationally critical and sensitive in nature. The Revenue Recovery Analyst will support the RCM collection team with training and escalated claim follow up. The Revenue Recovery Analyst performs payment variance deep dive and review activities related to the incorrect processing of claims across company. This position will focus on the resubmission, reprocessing and correcting of denied or rejected/exhausted insurance claims (2nd Level) as well as all high-volume facilities, top payors, and high-level complex claim issues.

Essential Functions: Essential functions encompass the required tasks, duties and responsibilities performed as part of the job and the reason the job exists.

  • Utilize independent judgment and exercise discretion to ensure timely review and auditing of underpaid claims.
  • Analyze, collect underpayments and resolve claims with discrepancies from expected payment to ensure payors are in payment compliance with their contracted terms.
  • Compile billing, and payor documentation to create training documents.
  • Initiate and follow through with all relevant parties to ensure corrective actions are implemented (i.e., pursue underpayments, adjust expected reimbursement, address billing issues, negotiate settlements, etc.) according to payor specific processes.
  • Respond to payment discrepancies by creating appeal letters and articulating contract provisions to representatives from third party payors. Work directly with payor to recover payments.
  • Quantify payor trends and maintain productivity and accuracy standards in highly challenging environment. Prepare 2nd level appeals, recoveries and potential settlements
  • Ability to extrapolate complex claims data and payer information to accurately report trends and payor behaviors.
  • Develops dashboards and reports on key performance indicators, metrics, data points, and formulas to support management objectives.
  • Extract, load and reconcile large data sets from multiple system platforms and sources.
  • Review data to determine operational impacts, trends and areas for improvement.
  • Follow up on claim submissions to determine batch acceptance, rejection, or denial in a timely manner.
  • Research, correct, resolve, resubmit and appeal denied claims/services. Corresponds with insurance companies to resolve the issue; submits appeals per payor requirements.
  • Maintains collections rate for assigned payors at or above 70% of allowed charges.
  • Communicate with RCM leadership about payor updates, changes, and requirements.
  • Sort and file paperwork from health plans, patient charts, and payment correspondence.
  • Update Division of Financial Risk (DOFR) quarterly with staff and report issues to Manager.
  • Support the team in their efforts to provide payors with information or documentation necessary for payment of claims and/or any other account follow up required to recover payment within a required timeframe.

Licensure and/or Certification Requirements:

  • Coding certificate is a plus.

Minimum Education:

  • Associates Degree required in related field.
  • Bachelor’s Degree preferred or equivalent experience in related field.

Minimum Work Experience:

  • A minimum of 5 years of experience as a medical biller/claims follow-up specialist or collections specialist in an outpatient medical setting (non-hospital) in primary care (required), family planning, ob-gyn, and related surgeries.
  • Advanced knowledge of medical terminology and common industry abbreviations, anatomy and physiology, pharmacology, and pathophysiology.
  • Knowledge of payor guidelines, industry billing and coding standards and Medi-Cal denials reason codes.
  • Computer database management (electronic practice management system). EclinicalWorks/NextGen experience preferred.
  • A minimum of 5 years of experience with insurance billing, coding and reimbursement procedures.
  • A minimum of 5 years of experience with HIPAA 5010 transaction standards.
  • A minimum of 5 years of experience claims follow-up/appeals and health plan Accounts Receivable management for specific payors.

Interested in hearing more? Easy Apply now by clicking the “Apply Now” button.