Authorization Denials Representative

150 Shriners Hospitals for Children; United States; On-site; USD 42,000 - 66,000; Full time

Job summary

Shriners Children’s is seeking an Authorization Denials Representative to follow up with payers after appeals. You will verify records, coordinate with Utilization Review, and ensure timely payment for SHC.

The role requires attention to detail and collaboration with team members. You will maintain tracking tools, prepare reports, support committee materials, and participate in initiatives of the Authorization Denials Management team.

Qualifications

• 1-3 years of healthcare revenue cycle experience.
• Knowledge of Healthcare Revenue Cycle revenue management.
• Knowledge of 837I, 837P, 835 and EOB responses.
• Knowledge of insurance contract rates and terms.
• Knowledge of registration and authorization processes.
• Knowledge of government and managed care billing, coverage, authorization and payment rules.
• High School Diploma/GED.

Responsibilities

• Coordinate payer denial and appeal follow up with third-party payers.
• Maintain healthcare tracking tool to store denial and review activity.
• Collect and analyze reports on status, metrics, and trends.
• Distribute reports to distribution groups.
• Organize data for timely follow up on appeals.
• Coordinate materials for committee meetings and prepare analyses.
• Support Authorization Denials Management projects.
• Verify concurrent review records with payers and UR.

Skills

Healthcare revenue cycle experience

Insurance billing knowledge

Government and managed care billing

Education

High School Diploma/GED

Bachelor's degree

Tools

Epic EMR

SQL

Crystal Reports

Job description

Company Overview

Shriners Children’s is an organization that respects, supports, and values each other. Named as the 2025 best mid-sized employer by Forbes, we are engaged in providing excellence in patient care, embracing multi-disciplinary education, and research with global impact. We foster a learning environment that values evidenced based practice, experience, innovation, and critical thinking. Our compassion, integrity, accountability, and resilience define us as leaders in pediatric specialty care for our children and their families. With 20+ hospitals, outpatient clinics, ambulatory care centers and outreach locations across the globe, we provide excellent care to children up to age 18 regardless of their family’s ability to pay or insurance status. Please click here to learn more about our locations.

Job Description

The Authorization Denials Representative is responsible for following up on payor responses to SHC submitted appeals. They will contact insurance carriers to ensure timely payment and collection of money due to the SHC organization after the appeals process has successfully taken place. The representative will verify that concurrent review medical records have been received by the payer and will communicate with Utilization Review if records are not on file.

Key Responsibilities

• Coordinates payer denial and appeal follow up activities to ensure appeals are on file and are being processed by the third-party payer, to include ensuring the payer has all documentation required to process the appeal.
• Maintains the healthcare tracking tool/application that stores/communicates all denial and review activity. This will include user access management, updates to software, and end-user training to support all follow up activities.
• Collects/analyzes report status, metrics and trends of activity by different reviews from the tool.
• Distributes reports on a routine basis to specific distribution groups.
• Organizes all data and activity in a retrievable way to ensure timely follow up on appeals to third party payors.
• Assists with the coordination of denial and review activities and materials for committee meetings, including analyses, reports, etc.
• Supports projects and initiatives of the Authorization Denials Management team.
• This may include coordinating meetings, conducting research for payer criteria, and preparing documents.
• Verifies concurrent review medical records have been received by the third-party payer and communicates with UR if additional submission is required.

Required Qualifications

• 1-3 years of healthcare revenue cycle experience
• Knowledge of Healthcare Revenue Cycle revenue management
• Knowledge of transaction sets including 837I, 837P, 835 and EOB responses
• Knowledge of insurance contract rates and terms
• Knowledge of registration and authorization processes
• Knowledge of government and managed care billing, coverage, authorization and payment rules
• High School Diploma/GED

Preferred Qualifications

• Epic EMR experience
• Knowledge of SQL or Crystal Reports
• Bachelor's degree

Compensation is determined based on years of relevant experience and departmental equity.

Every day, we provide innovative, compassionate care and conduct leading research that enhances the quality of life for children and their families. We invite you to explore the many rewarding career paths at Shriners Children's, from clinical and non-clinical positions to education and research opportunities. We’re always looking for driven, compassionate professionals to join our team as nurses, physical therapists, medical assistants, administrative staff and much more.

No matter where you're located, you'll find openings at our Shriners Children’s facilities across the U.S., in Canada and Mexico and at our corporate headquarters in Tampa, Florida.

• Eligible Shriners Children’s employees receive comprehensive benefits packages, including medical, dental and vision insurance, tuition assistance, retirement matching and so much more!