Medical Billing - Denials Expert

Work From Home Opportunity
Direct Client | Full-Time
Schedule: PST Business Hours

We are looking to hire three individuals for the following roles:

Senior Full-Time Role: This position is ideal for someone with extensive experience who can take on a more senior role within the team.
Full-Time (Short-Term): A full-time position expected to last approximately three months, with the possibility of transitioning to part-time depending on future growth.
Full-Time (Short-Term): Another full-time role for an estimated duration of three months, with the potential to become part-time based on organizational growth.

We are seeking a detail-oriented and experienced Denial Analyst & Appeals Specialist to join our team. This role focuses on managing claim denials for preventive care, obesity-related treatments, and chronic disease programs. The ideal candidate will leverage their expertise in medical billing, coding, and appeals to analyze denial trends, prepare compelling appeal letters,
and collaborate with cross-functional teams to optimize revenue cycle performance. Key responsibilities include handling denials related to medical necessity, prior authorizations, timely filing, and preventive care services, while ensuring compliance with payer policies and clinical guidelines. This position offers an opportunity to contribute to a mission-driven organization
dedicated to improving healthcare outcomes.

Key Responsibilities:

1. Denial Analysis & Appeals Preparation:
? Review Explanation of Benefits (EOBs) and remittance advice to determine the root cause of denials.
? Draft and submit detailed, payer-specific appeal letters for denied claims related to preventive services, obesity-related treatments, and chronic disease programs.

2. Preventive Care Denials:
? Manage appeals for services denied due to frequency limitations, payer misinterpretations of coverage, or missing documentation.
? Use expertise in coding and modifier combinations (e.g., modifier 25 for same-day preventive and problem-oriented visits) to support successful reimbursement.

3. Prior Authorization & Referral-Related Denials:
? Handle appeals for claims denied due to missing or delayed prior authorizations and referrals.
? Submit retroactive authorization requests when necessary and escalate payer errors that violate preventive care mandates.

4. Timely Filing Denials:
? Manage appeals for claims denied due to late submissions, including creating bulk appeals with detailed explanations (e.g., system transitions, retroactive enrollments).
? Negotiate timely filing waivers by demonstrating good faith efforts and valid delays.

5. Medical Necessity Denials:
? Address medical necessity denials for obesity-related services (e.g., nutrition counseling, behavioral therapy, pharmacotherapy).
? Prepare appeals referencing clinical guidelines (e.g., USPSTF recommendations) and including supporting documentation such as BMI calculations, progress notes, and care plans.

6. Denial Trends Reporting:
? Track and report on denial trends, appeal success rates, and payer-specific issues.
? Suggest process improvements to prevent recurring denials and optimize revenue cycle performance.

7. Cross-Team Collaboration:
? Partner with coding, payments, and eligibility teams to resolve complex claims issues.
? Provide feedback to improve processes and reduce denials at the point of claim submission.

Qualifications:
? Experience: Minimum 3-5 years of medical billing and denial management experience, preferably handling claims for preventive care and chronic disease programs.
? Expertise in Appeals: Strong knowledge of clinical and administrative denial appeals for commercial, government, and private payers in the U.S. healthcare system.
? Education: Bachelor’s degree or relevant certification in Medical Billing and Coding (preferred but not required).
? Technical Proficiency: Familiarity with EHR, billing software, and insurance portals (experience with platforms like Kareo, Athenahealth, or Epic is a plus).
? Detail-Oriented: Exceptional attention to detail and ability to identify patterns in denials.
? Communication Skills: Strong written and verbal communication skills to craft effective appeals and collaborate with cross-functional teams.
? Time Management: Ability to manage multiple clinics’ billing needs and meet deadlines in a fast-paced environment.

Preferred Qualifications:
? Experience with preventive care billing, including annual wellness visits, screening tests, and obesity-related services.
? Understanding of CPT, ICD-10, and HCPCS codes, particularly those related to preventive and chronic disease management.

Compensation and Benefits:
? Competitive salary based on experience.
? Performance-based incentives.
? Flexible remote work environment.
? Opportunity to work with a mission-driven, growing company focused on improving healthcare outcomes.

How to Apply:
If this role resonates with you, please submit your resume and cover letter detailing your interest to Upgrade to see actual info the subject line: Medical Billing - Denials Expert Application.

Due to the volume of applications we receive, not all applicants will receive a response. Thank you for your understanding.