Denials Management Specialist Job at UC San Diego (San Diego)

Job Description

UC San Diego Health's Revenue Cycle department supports the organization's mission to deliver outstanding patient care and to create a healthier world — one life at a time. We are a diverse, patient-focused, high-performing team with a commitment to quality, collaboration, and continuous improvement that enables us to deliver the maximum standard of care to our patients. We offer challenging career opportunities in a fast-paced and innovative environment and we embrace individuals who demonstrate a deep passion for problem-solving and customer service.

Job Responsibility

Supports essential facility revenue cycle operations with primary focus on denials resolution, payer follow-up, reimbursement recovery, and account receivable reduction
Researching denied accounts, identifying root causes, resolving payer barriers, submitting appeals or reconsiderations when appropriate and escalating complex issues that requiring coding, clinical, billing, contract, or payer intervention

Requirements

Minimum of 4 years of recent healthcare revenue cycle experience, preferably in hospital/facility billing, payer follow-up, collections, denials, or account resolution including experience researching and resolving denied, unpaid, or underpaid healthcare claims
HFMA Certified Revenue Cycle Representative (CRCR) required or within 120 days of employment
Experience with hospital billing and collections, including specialty billing, reimbursement follow up, denial and claim rejection trending and follow up
Expert knowledge of medical insurance and State and Federal rules and regulations related to billing Insurance Claims
Knowledge of accounting and cash handling principles and various billing documents and claim forms
Extensive knowledge in Insurance claims appeals with extensive experience in use and understanding of coding as well as demonstration of coding guidelines including medical and surgical terminology
Excellent verbal and written communication skills and able to promote and maintain superb communication in the following relationships: peer to peer, management, third party payors, patients and departments within UCSD
Must demonstrate reliability, communicate constructively, actively listen, function as an active participant, share openly and willingly, cooperate and pitch in to help, exhibit flexibility, show commitment to the team(s), work as a problem-solver, and treat others in a respectful, professional and supportive manner
Expertise using Excel, Word and Outlook
Knowledge of home infusion and pharmacy billing with strong knowledge base of Specialty Infusion billing
A self-starter who is accountable and requires minimal direction and supervision
a person who is open to new ideas
and a creative and flexible individual who is comfortable working in a large, complex organization

Nice to have

Working knowledge of payer follow-up, claim status research, remittance review, payer correspondence, and account documentation
Ability to interpret denial reason codes, remittance activity, payer responses, and claim status information to determine appropriate next steps
Demonstrated ability to manage high-volume/high dollar account work while maintaining accuracy, productivity, and compliance
Recent acute care hospital/facility denials resolution experience
Recent Epic HB Resolute experience supporting hospital billing, payer follow-up, denials
Knowledge of UB-04/CMS-1450 facility claim requirements, including bill type, condition codes, occurrence codes, value codes, revenue codes, HCPCS/CPT codes, modifiers, diagnosis codes, and payer-specific billing requirements
Understanding of the relationship between revenue codes, HCPCS/CPT codes, modifiers, diagnosis codes, authorizations, and facility reimbursement
Experience resolving facility denials related to authorization, medical necessity, coding, billing edits, timely filing, eligibility, coordination of benefits, payer processing, reimbursement disputes, and underpayments
Ability to distinguish between clinical denials and technical/administrative denials and determine the appropriate resolution pathway, including clinical review, coding review, authorization follow-up, corrected claim, payer escalation, or administrative appeal action
Experience submitting or supporting appeals, reconsiderations, corrected claims, payer portal disputes, and medical record submissions
Strong critical thinking skills with the ability to identify denial root causes, determine appropriate account resolution pathways, and escalate recurring denial trends
Familiarity with CARC/RARC codes, remittance advice, payer correspondence, and claim adjustment logic
Understanding of facility reimbursement concepts such as DRG, per diem, percent of charges, case rates, carve-outs, bundled services, and payer contract/payment methodology basics
Experience collaborating with billing, coding, revenue integrity, patient access, utilization management, clinical appeals, contracting, or payer representatives to resolve complex denials

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Denials Management Specialist

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