Billing and Collections Specialist, RMF Denials Management

DHR Health; Edinburg (TX); On-site; USD 38,000 - 52,000; Full time

Benefits offered by this job

DHR CARES program

Job summary

DHR Health in Edinburg, TX seeks a Billing and Collections Specialist in RMF Denials Management. You will review denied claims, draft appeals, and support education across Revenue Cycle with a focus on accurate reimbursement and compliance.

The role emphasizes accuracy, communication, and adherence to guidelines. The ideal candidate has exposure to EMR workflows, strong billing knowledge, and bilingual English/Spanish abilities.

Qualifications

• High School Diploma/GED required.
• 0-2 years in denial management, utilization review or prior authorization in hospital/provider setting.
• Experience in healthcare billing and reimbursement.
• Experience with EMR workflows.
• Strong knowledge of healthcare reimbursement methodologies.
• Knowledge of claim forms and remittance advice, including coding and billing practices.
• Ability to interpret contract language.
• Proficient with Microsoft Office; excellent customer service.
• Bilingual English/Spanish preferred.
• Previous healthcare/hospital experience preferred.

Responsibilities

• Promote facility mission and values in service delivery.
• Demonstrate expertise in denials and appeals.
• Draft detailed appeal letters with necessary information.
• Follow up on insurance accounts and ensure timely resolution.
• Adhere to Medicare/Medicaid billing guidelines when interacting with carriers.
• Utilize various software to verify eligibility and claim status.
• Billing and follow-up on claims using online or billing software.
• Access payer websites to retrieve information as needed.
• Understand managed care contracts to determine reimbursement levels.
• Address discrepancies with insurance carriers.
• Contact patients to gather additional information for insurance purposes.

Skills

Denials management

Customer service

Medical terminology

ICD-10 codes

CPT/HCPCS codes

EMR workflows

Microsoft Excel

Bilingual EN/ES

Typing 35 WPM

Education

High School Diploma/GED

Tools

EMR system

Job description

Billing and Collections Specialist, RMF Denials Management - 21293

US:TX:Edinburg | Financial Services | Full Time

Posted 3 weeks ago

Description

DHR Health - US:TX:Edinburg - Days

Summary:

MISSION STATEMENT:

Our Mission is to improve the well-being of those we serve with a commitment to excellence: every patient, every encounter, every time.

VISION:

Our Vision is to create a world-class health system to advance medicine and increase access for the communities we serve by empowering caregivers to heal through compassion, knowledge, innovation, integrated care and excellence.

POSITION SUMMARY:

The Billing and Collections Specialist in the RMF Denials Management department is responsible for conducting quality assurance reviews on denied claims. When an appeal is necessary, the specialist drafts the appeal to payers using relevant clinical indicators, official coding guidelines, and documentation from the patient’s medical record. Basic knowledge of medical terminology, CPT/HCPCS codes and ICD10 codes. Additionally, the specialist plays a crucial role in reporting quality results, tracking and identifying educational opportunities within the Revenue Cycle departments, addressing client subject matter needs, and contributing to educational support and training efforts.

POSITION EDUCATION/ QUALIFICATIONS:

• High School Diploma/GED is required
  0-2 years of experience in denial management, utilization review or prior authorization in a hospital, provider, or healthcare system.
  Experience in healthcare billing and reimbursement
  Experience with EMR system workflows
  Strong knowledge of health care services reimbursement methodologies
  Knowledge of claim forms and remittance advice, including coding and billing practices
  Ability to interpret contract language
  Working knowledge of medical terminology
  Knowledge of Microsoft Office Suite
  Excellent Customer Service
  Bilingual- English/Spanish, preferred
  Previous healthcare and hospital/professional experience preferred.
  Ability to use the internet to obtain information from Third Party Payers or other sources is required.
  Requires working with minimal to moderate interruptions

JOB KNOWLEDGE/EXPERIENCE:

Previous healthcare and hospital/professional experience preferred.
Communicates clearly and concisely and is able to work effectively with other employees, patients and external parties

Establishes and maintains long-term customer relationships, building rapport with other department staff

Demonstrates proficiency in Microsoft Office applications, be able to type at least 35 WPM, and good working knowledge of Excel is required.

Able to perform basic mathematical calculations, balance and reconcile figures, punctuate properly and spell correctly.

Medical Terminology, ICD – 10, Codes, CPT Codes, HCPCS code, Modifier knowledge required.

Ability to use the internet to obtain information from Third Party Payers or other sources is required.

Requires working with minimal to moderate interruptions

Occasional evening or weekend work may be required

Responsibilities:

POSITION RESPONSIBILITIES:

Promote Facility Mission: Advocate for the facility’s mission, vision, and values by effectively communicating them and incorporating them into service development, standards, and practices.
Denials and Appeals Proficiency: Demonstrate expertise in handling denials and appeals.
Create Appeal Letters: Draft detailed appeal letters with all necessary information.
Follow‑Up on Insurance Accounts: Manage and follow up on assigned insurance accounts
Adhere to Billing Guidelines: Follow governmental billing and collection rules as outlined in Medicare/Medicaid manuals when interacting with insurance carriers.
Software Proficiency: Utilize different software systems to verify eligibility and claim status
Billing and Follow‑Up: Demonstrate proficiency in billing and following up on claims using online or billing software.
Payer Website Access: Access payer websites as needed to retrieve information.
Managed Care Contract Knowledge: Understand managed care contract terms to determine correct reimbursement levels.
Reimbursement Comparison: Compare payer reimbursement to expected payments and address discrepancies with insurance carriers.
Patient Contact: Contact patients to gather additional information for insurance purposes, if needed.
Fax and Message Follow‑Up: Address faxes or messages from carriers within 24 hours to ensure timely and compliant resolution of denials.
Account Follow‑Up: Follow up on assigned Accounts Receivable trackers or custom reports, contacting insurance carriers for payment or recoupments.
Notes: Enter appropriate notes in host system
Correspondence Response: Respond to insurance carrier correspondence in a timely manner.
Insurance Billing: Identify accounts needing insurance billing/ rebilling or appeal
Appeal Management: Enter and maintain appealed accounts using appropriate indicators in host system
Compliance Notification: Notify management of any compliance concerns or incidents.
HIPAA Compliance: Ensure patient confidentiality is maintained in accordance with HIPAA policies and procedures.
Educational Participation: Attend educational conference calls and complete HealthStream learning modules on time.
Productivity and Quality: Maintain required productivity and quality standards, and adhere to QA process requirements.
Cross‑Training: Work towards cross‑training and familiarizing oneself with both professional and facility denials.
Other duties as assigned.

LINES OF REPSONSIBILITIES:

(Chain-of-command) Billing and Collections Supervisor → 2. Billing and Collections Manager → 3. VP of Revenue Cycle → 4. Chief Revenue Officer

Other information:

CUSTOMER SERVICE:

Provide excellent customer service to all DHR customers. All employees are required to attend the DHR C.A.R.E.S program which outlines the Customer Service Principals including: Commitment, Accountability, Respect, Excellence and Service.

AGE SPECIFIC:

Employees must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served in his/her assigned unit. The individual must demonstrate knowledge of principles of growth and development over the life span and possess the ability to assess data reflective of the patient’s status and interpret the appropriate information needed to identify each patient’s requirement relative to his or her age.

AMERICANS WITH DISABILITIES ACT: (ADA):

A. Essential Duties: Indicated by bold print within performance standards, preceding individual numbered criteria.

Light/moderate lifting up to 20 lbs., from the floor to shoulder height.

Yes

Kneeling

Yes

Must be able to assist other employees with lifting more than 20 lbs.

Yes

Walking

Yes

Light/moderate carrying up to 20 lbs.

Yes

Yes

Straight pulling

Yes

Yes

Pulling hand over hand

Yes

Pushing

Yes

Repeated bending

Yes

Yes

Reaching above shoulder

Yes

Yes

Yes

Climbing Ladders

No

Dual simultaneous grasping

Yes

Depth Perceptions needed

Yes

Ability to see

Yes

Yes

Operating office equipment

Yes

Twisting

Yes

Operating mechanical equipment

Yes

No

Ability to read and write

Yes

Ability to Count

Yes

Ability to hear verbal communication without aid

Yes

Operating Personal Vehicle

Yes

Ability to comprehend written/verbal communication

Yes

Other: Ability to deal with stress

Yes

OSHA Category

III

B. Working Conditions: The individual spends over 95% of his/her time in an air-conditioned environment with varying exposures to noise. There is protection from weather conditions but not necessarily from temperature changes. The position does have low exposure to malodorous, infectious body fluids from patients and some minimal exposure to noxious smells from cleansing agents.

C. Occupational Exposure: This position has minimal to no exposure to blood, body fluids, or tissues and is an OSHA Category III (although situations can be imagined or hypothesized under which anyone, anywhere, might encounter potential exposure to body fluids). Person who performs these duties are not called upon as part of their employment to perform or assist in emergency medical care or first aid or to be potentially exposed in some other way.

Intelligence: General learning ability: The ability to “catch on” or understand instructions and underlying principles. Ability to reason and make judgments. 3

Verbal: Ability to understand meanings of words and ideas associated with them, and to use them effectively. To comprehend language, to understand relationships between words, and to understand meanings of whole sentences and paragraphs. To present information or ideas clearly. 3

Numerical: Ability to perform arithmetic operations quickly and accurately. 2

Spatial: Ability to comprehend forms in space and understands relationships of plane and solid objects. Frequently described as the ability to “visualize” objects or two or three dimensions, or to think visually of geometric forms. 2

Form Perception: Ability to perceive pertinent details and objects or in pictorial or graphic material to make visual comparisons and discriminations and see slight differences in shapes and shadings of figures and widths and lengths of lines. 3

Clerical Perception: Ability to receive pertinent details and verbal or tabular material. To observe differences in copy, to proofread words and numbers, and to avoid perceptual errors in arithmetic computation. 2

Motor Coordination: Ability to coordinate eyes and hands to fingers rapidly and accurately in making precise movements with speed. Ability to make a movement response accurately and quickly.

Finger Dexterity: Ability to move hands easily and skillfully. To work with fingers in placing and turning motions. 3

Manual Dexterity: Ability to move hands easily and skillfully. To work with hands in placing and turning motions. 3

Eye-Hand-Foot Coordination: Ability to move the hand and foot coordinately with each other in accordance with visual stimuli. 3

Color Discrimination: Ability to perceive and respond to similarities or differences in colors, shapes, or other values of the same or different color. To identify a particular