Clinical Denials Specialist

WVU Medicine; Core (WV); On-site; USD 35,000 - 50,000; Full time

Job summary

WVU Medicine is looking for a detail-oriented individual to manage accounts receivable related to denied claims. You will investigate denials, follow up with insurers, and ensure compliance with billing regulations.

Applicants should have a high school diploma, and one year of experience in medical billing is preferred. Knowledge of EPIC billing and proficiency in Microsoft Office is essential. This role offers a standard schedule of 40 hours per week in a business environment.

Qualifications

• One year of training in medical billing, coding, insurance processing, or related experience.
• Experience with hospital billing is preferred.

Responsibilities

• Manage accounts receivable for denied claims.
• Follow up with insurance companies about claim denials.
• Compose non-clinical appeals and manage submissions.
• Ensure compliance with federal and state regulations.

Skills

Excellent customer service

Oral and written communication skills

Basic computer knowledge

Knowledge of medical terminology

Excellent telephone skills

Education

High School diploma or equivalent

Associate degree in related field

Tools

EPIC medical billing

Microsoft Excel

Microsoft Word

Job description

This position is responsible for managing accounts receivable related to denied claims to ensure the financial viability of the WVU Medicine hospitals. This includes, but is not limited to, denial investigation, follow‑up with insurance companies, billing, auditors and clinics/hospital departments, non‑clinical appeal writing, accurate and timely account adjustments all while ensuring compliance with all federal, state, third‑party billing regulations and contract agreements. Employs excellent customer service, oral and written communication skills. Works with leadership and other team members to achieve best‑in‑class revenue cycle processes.

Minimum Qualifications

Education, Certification, and/Or Licensure

• High School diploma or equivalent.

Experience

• One (1) year of training in medical billing, coding, insurance processing, or other related experience.

Preferred Qualifications

Education, Certification, and/Or Licensure

• Associate degree in related field
• Knowledge and experience with EPIC medical billing
• Experience with Microsoft Excel/Word

Experience

• Experience with hospital billing.

Core Duties and Responsibilities

• Accurately triage and route claims to work queues by maintaining a working knowledge of system hospital/clinic departments, procedures and payer appeal processes and deadlines.
• Follow up with third‑party payers to clarify payment remit issues, ensure timely appeal receipt/process/resolution; adhere to appropriate procedures and timelines and upgrade payer behavior issues to management.
• Utilize payer portals and payer websites to verify appeal status and conduct account follow‑up, contacting payers by telephone when needed.
• Compose administrative, non‑clinical appeals as directed by leadership. Organize and manage appeal letter submissions via mail or other portals.
• Develop and maintain working knowledge of all federal, state, and local regulations pertaining to hospital billing compliance regulations.
• Maintain work queue volumes and productivity within established standards. Adhere to timely filing guidelines for work queue prioritization.
• Post adjustments as directed or by following department SOP, ensuring accurate and timely processing, and validating based on contract pricing/payer models.
• Manage and distribute incoming mail in an accurate and timely manner; include Epic documentation, logging incoming correspondence, uploading to document warehouse and routing mis‑directed mail; process outgoing certified mail.
• Communicate problems hindering workflow to management in a timely manner; provide suggestions to increase workflow efficiency.
• Participate in educational programs to meet mandatory requirements and identified needs regarding job and personal growth.
• Attend department meetings, teleconferences, and webinars as necessary or directed.
• Provide excellent customer service to patients, employees, vendors, and auditors.
• Utilize Microsoft Office or other applications as needed to complete job functions, specific reporting, or project management.

Physical Requirements

• Manual dexterity used in operating standard office equipment.
• Prolonged periods of sitting.
• May be required to walk to various areas throughout the department or medical complex. This may require the use of stairs and/or elevators.

Working Environment

• Business Environment.

Skills and Abilities

• Basic computer knowledge and ability to operate standard office software.
• Knowledge of medical terminology preferred.
• Prior experience with Microsoft Office Suite software applications, including, but not limited to, Word, Excel, Access, Power Point and Outlook is preferred.
• Good verbal and writing skills.
• Basic mathematical skills.
• Excellent telephone skills.
• Ability to type at least 35 WPM preferred.

Additional Job Description

• Scheduled Weekly Hours: 40
• Exempt/Non‑Exempt: United States of America (Non‑Exempt)
• Shift: United States of America (Non‑Exempt)
• Company: SYSTEM West Virginia University Health System
• Cost Center: 661 SYSTEM Clinical Denial Management