Medical Claims & Denials Specialist (RCM)

KMC Solutions; Metro Manila; Sur place; PHP 201 000 - 357 000; Plein temps

Résumé du poste

KMC Solutions in the Philippines seeks a Medical Claims & Denials Specialist (RCM) to review denied or underpaid claims, coordinate appeals, and collaborate with billing and coding teams to improve denial outcomes.

The role emphasizes accurate documentation, timely follow-ups, and adherence to payer regulations, with a focus on improving denial trends and payments. Strong communication and cross-functional teamwork are essential.

Qualifications

• At least 2 years of experience in Revenue Cycle Management (RCM).
• Experience in medical claims processing, denial management, medical billing, or accounts receivable (AR) is an advantage.
• Knowledge of medical claims review, denial resolution, appeals, and payer follow-up processes.
• Familiarity with denial management software, Electronic Health Record (EHR) systems, or medical billing platforms is preferred.
• Strong analytical and problem-solving skills, with attention to detail and accuracy.
• Good written and verbal communication skills.
• Ability to collaborate effectively with cross-functional teams and manage multiple claims-related tasks.

Responsabilités

• Review denied or underpaid claims to identify denial reasons.
• Submit appeals with required documentation or corrections.
• Communicate with insurers to resolve outstanding claims issues.
• Ensure timely follow-ups on unresolved claims to secure payment.
• Coordinate with coding and billing to ensure correct claim submission.
• Gather supporting documentation for claims appeals and resubmissions.
• Maintain records of denied claims, appeals, and resolutions.
• Prepare basic reports on denial trends for internal review.
• Monitor denial rates, appeal success, and resolution times.
• Support workflow improvements in denial management and payer compliance.

Connaissances

Revenue Cycle Management

Claims processing

Denial management

Medical billing

Admission AR

Analytical skills

Communication skills

Cross-functional collaboration

Attention to detail

Outils

EHR systems

Denial management software

Medical billing platforms

Description du poste

Medical Claims & Denials Specialist (RCM)

Position Overview

The Medical Claims & Denials Specialist is responsible for reviewing and resolving denied or underpaid medical claims, ensuring timely follow-ups on outstanding issues, and supporting initiatives to reduce future claim denials.

This role involves working closely with billing and coding teams to correct claims, prepare appeals, and ensure compliance with payer regulations. The specialist will also analyze denial patterns, maintain accurate records, and contribute to process improvement initiatives.

Key Responsibilities

1. Claims Review and Resolution

• Review and analyze denied or underpaid medical claims to identify the reasons for denial.
• Take appropriate actions to appeal denied claims by submitting the necessary documentation or corrections.
• Communicate with insurance companies and payers to resolve outstanding claims issues.
• Ensure timely follow-ups on unresolved claims to facilitate prompt payment.

2. Documentation and Coding Assistance

• Coordinate with coding and billing teams to ensure claims are accurately coded and submitted according to payer guidelines.
• Identify common coding or documentation errors that contribute to claim denials and collaborate with relevant teams to address them.
• Assist in gathering supporting documentation for claims appeals and resubmissions.

3. Tracking and Reporting

• Maintain accurate records of denied claims, appeals, and resolutions using denial management software or Electronic Health Record (EHR) systems.
• Prepare basic reports on denial trends for internal review and help identify recurring issues and improvement opportunities.
• Monitor key performance metrics, including denial rates, appeal success rates, and resolution times.

4. Process Improvement Support

• Identify opportunities to improve denial management workflows and recommend ways to enhance operational efficiency.
• Support the implementation of initiatives aimed at reducing claim denial rates.
• Participate in training sessions related to medical coding, billing, denial management, and payer regulations.

5. Compliance and Policy Adherence

• Ensure all denial management activities comply with applicable federal, state, and payer regulations.
• Stay updated on payer policies and requirements to support accurate claims submissions.
• Follow internal guidelines and established procedures when managing denied claims and appeals.

6. Collaboration and Communication

• Work closely with internal departments, including coding, billing, and compliance teams, to resolve claims-related issues.
• Respond to inquiries from insurance companies, patients, and internal stakeholders regarding claim statuses and denial reasons.
• Escalate complex or unresolved claims issues to senior specialists or management for further review.

Qualifications and Requirements

• At least 2 years of experience in Revenue Cycle Management (RCM).
• Experience in medical claims processing, denial management, medical billing, or accounts receivable (AR) is an advantage.
• Knowledge of medical claims review, denial resolution, appeals, and payer follow-up processes.
• Familiarity with denial management software, Electronic Health Record (EHR) systems, or medical billing platforms is preferred.
• Strong analytical and problem-solving skills, with attention to detail and accuracy.
• Good written and verbal communication skills.
• Ability to collaborate effectively with cross-functional teams and manage multiple claims-related tasks.