Denial Appeals Specialist

Memorial Health System; Springfield (IL); On-site; USD 25,265 - 39,151; Full time

Job summary

Memorial Health System is seeking a Billing Specialist to analyze and resolve Medicaid claims, ensuring compliance with Medicaid guidelines and internal policies. The role supports inpatient and outpatient billing across multiple departments.

The ideal candidate has 2+ years in health care billing, proficiency with Medicaid software, and strong communication and problem-solving skills. This on-site position offers opportunities for process improvements and cross-training.

Qualifications

• Education equivalent to graduation from high school or GED is required.
• Two or more years of insurance and/or health care billing experience is required.
• Experience with Medicaid billing and related software (IDPA payment system, SMS, and NEBO) is highly preferred.

Responsibilities

• Utilizes electronic software to determine Medicaid insurance eligibility and coverage for inpatient and/or outpatient Medicaid claims.
• Receives and examines daily listings for assigned billing claims and determines which require further analysis and action.
• Investigates assigned billing claims with incomplete/incorrect information and resolves problems to ensure complete and Medicaid-compliant information accompanies the claim.
• Prioritizes claims based on specified criteria and electronically files the claim, ensuring adherence to Medicaid guidelines, timeliness, accuracy, and processing procedures.
• Follows up and investigates unpaid items and other issues associated with unpaid claims; contacts patients, guarantors, or other sources of payment and secures arrangements for prompt payment.
• Receives and researches Medicaid claim denials, and as necessary, prepares paperwork to appeal the denial.
• Reviews correspondence relating to Medicaid payments and claims; conducts research to provide background information regarding inquiries.
• Researches and resolves complex issues associated with Medicaid accounts and reports problematic trends to management.
• Analyzes reports containing rejected account information and resolves the reason(s) for the rejection.
• Provides input regarding system edits to ensure data for Medicaid claims processing is compliant.
• Responds to requests from internal departments regarding proper coding, billing, and processing of Medicaid claims.
• Communicates with internal and external sources to resolve Medicaid claim issues.

Skills

Medicaid billing

Insurance billing

Microsoft Word

Microsoft Excel

Multi-tasking

Communication skills

Problem solving

Medical terminology

CPT coding

ICD-9 coding

Education

High school diploma or GED

Tools

IDPA payment system

SMS

NEBO

Job description

Min

Min USD $18.34/Hr. Max USD $28.42/Hr.

Overview

Analyzes, investigates, and resolves claims/billing information and/or errors associated with inpatient and outpatient Medicaid claims. Ensures compliance with Medicaid guidelines and MMC organizational policies. Embodies the Memorial Health System Performance Excellence Standards of Safety, Courtesy, Quality, and Efficiency that support our mission, vision and values.

Qualifications

Education:

Education equivalent to graduation from high school or GED is required.

Experience:

Two or more years of insurance and/or health care billing experience is required. Previous experience with Medicaid billing and software (IDPA payment system, SMS, and NEBO) is highly preferred.

Other Knowledge/Skills/Abilities:

• Basic working knowledge of personal computers and their associate user software is required. Experience with Microsoft Office products Word and Excel is preferred.
• Ability to multi-task while working on multiple responsibilities simultaneously.
• Demonstrated ability to work successfully with internal customers and external contacts is required.
• Possesses a highly-developed critical thinking and problem solving-ability to work through complex situations.
• Demonstrates excellent oral and written communication, keyboarding, basic math, and problem solving skills.
• Familiarity with medical terminology, medical procedural (CPT) and diagnosis (ICD-9 CM) coding, and hospital billing claim form UB-04 is highly preferred.

Responsibilities

Principal Duties & Responsibilities:

• Utilizes electronic software to determine Medicaid insurance eligibility and coverage for inpatient and/or outpatient Medicaid claims.
• Receives and examines daily listings for assigned billing claims and determines which require further analysis and action.
• Investigates assigned billing claims with incomplete/incorrect information and resolves problems or errors to ensure complete and Medicaid-compliant information accompanies the claim.
• Prioritizes claims based on specified criteria and electronically files the claim, ensuring careful adherence to Medicaid guidelines, timeliness, accuracy, and processing procedures. At prescribed intervals, follows up for review to ensure smooth processing and timely delivery of monetary reimbursements.
• Embodies the Memorial Health System Performance Excellence Standards of Safety, Courtesy, Quality, and Efficiency that support our mission, vision and values:
• Follows up and investigates unpaid items and other issues associated with unpaid claims. Contacts patients, guarantors, or other sources of third party payment and secures arrangements for prompt payment.
• Receives and researches Medicaid claim denials, and as necessary, prepares the necessary paperwork to appeal the denial.
• Reviews correspondence relating to Medicaid payments and claims; conducts the necessary research to provide supplementary background information regarding the inquiry.
• Researches and resolves complex issues associated with Medicaid accounts. As applicable, identifies, documents, and reports problematic trends to management.
• Analyzes reports containing rejected account information and performs the necessary research to resolve the reason(s) for the rejection and secures any other required information.
• Provides input regarding system edits designed to identify and ensure consistent and compliant data necessary for processing Medicaid claims.
• Responds to requests from internal departments regarding the proper coding, billing, and processing of Medicaid claims.
• Communicates and resolves issues with a variety of internal and external sources to resolves issues involving Medicaid claims. This may include internal departments, patients (or other responsible parties), third-party payors, social service agencies, Medicare/Medicaid staff, other insurance carriers, service providers, and collection agencies.
• Initiates corrections to charges and contractuals / allowances within scope of expertise and authority granted.
• Identifies and calculates write-off amounts and secures the necessary approvals from management for processing.
• Documents online systems and electronic files to ensure accurate data is noted regarding the status of claims and payments.
• Ensures compliance to Medicaid policy guidelines and processes at each work step to facilitate accurate and timely reimbursements to the organization.
• As directed and defined by management, orients and cross-trains on other unit duties which are outside of regularly assigned area of responsibility. May serve as a back-up for other areas within the unit or department, especially during times of special needs or staff absences.
• Performs other related work as required or requested.