Denial Appeals Specialist

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

Job summary

A major health organization in Springfield, Illinois, is seeking a professional to analyze and resolve Medicaid claims and billing issues. This position requires high school graduation or GED and two years of healthcare billing experience, especially with Medicaid. Candidates should possess skills in problem-solving, communication, and basic software like Microsoft Office. The role involves ensuring compliance with guidelines and managing complex billing issues to facilitate timely payments.

Qualifications

• Two or more years of insurance or health care billing experience.
• Previous experience with Medicaid billing preferred.

Responsibilities

• Utilizes software for Medicaid insurance eligibility and coverage.
• Investigates billing claims with incomplete information.
• Ensures compliance with Medicaid guidelines.

Skills

Basic working knowledge of personal computers

Experience with Microsoft Office products

Ability to multi-task

Critical thinking and problem-solving ability

Excellent oral and written communication skills

Familiarity with medical terminology

Education

High school graduation or GED

Tools

IDPA payment system

SMS

NEBO

Job description

Position Summary

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.

Compensation

USD $18.34/Hr. – USD $28.42/Hr.

Qualifications

• Education: Graduation from high school or GED.
• Experience: Two or more years of insurance and/or health care billing experience. 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 associated software; 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.
  • Highly‑developed critical thinking and problem‑solving ability to work through complex situations.
  • Excellent oral and written communication, keyboarding, basic math, and problem‑solving skills.
  • Familiarity with medical terminology, CPT and ICD‑9 CM coding, and the UB‑04 hospital billing claim form 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 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:
  • SAFETY: Prevent Harm – I put safety first in everything I do. I take action to ensure the safety of others.
  • COURTESY: Serve Others – I treat others with dignity and respect. I project a professional image and positive attitude.
  • QUALITY: Improve Outcomes – I continually advance my knowledge, skills and performance. I work with others to achieve superior results.
  • EFFICIENCY: Reduce Waste – I use time and resources wisely. I prevent defects and delays.
• 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 resolve 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.