Under general supervision the Accounts Receivable Denial Specialist is responsible for evaluating denials, underpayments, and undercharging for hospital and professional services in order to formulate appeals and recommend contract and charge enhancements that will maximize entitled reimbursement for the medical center. Responsible for timely follow-up of outstanding AR for all insurance carriers. Works diligently with government and third party insurance payers and other facilities as needed to resolve unpaid balances and ensure optimal payment on accounts as well as identify issues preventing full reimbursement on initial claims. Performs extensive telephone contact to the insurance companies to conclude payment on the denied claims. Utilizes medical center contract summaries to verify balances due on disputed claims. Provides staff training, coaching and support; issue identification, assessment and resolution; and technical support within the assigned work environment in order to achieve desired outcomes and compliance with medical center policies/procedures and standards. Participates in quality assessment and continuous quality improvement activities. Performs all job duties and responsibilities in a courteous and customer-focused manner according to the Hurley Family Standards of Behavior. Works under the direction of the Sr. Director / Directors or designee of hospital and professional billing services.

1. Reviews denials and initiates the appeal process with a focus on high-risk and/or high-dollar accounts. Monitors and follows up on denials and appeals, determining next steps (possibly including setting up arbitration with the payer) to ensure that either result in an overturned denial or that appeal proceeded to the appropriate level.


2. Analyzes initial and fatal denial data to identify trends and shares findings with revenue cycle leadership to drive process improvements. Recommends fatal denials for adjustment according to department guidelines.


3. Supports global denial prevention and mitigation efforts throughout the medical center. Attends and/or conducts meetings with insurance carrier representatives to present denial data in order to improve processes and efficiencies with such carriers.


4. Documents action taken on account to resolve denials, underpayments, or undercharging through the use of identified workflows in the patient financial system. Utilizes the system to drive workflows and work queue activity to appropriate sources. Records all phone activity, contacts, correspondence, and other action taken relative to accounts and participates in quality meetings to present, review and analyze established standards.


5. Reviews data relative to the types of denials and their root causes and collaborates with team members to make recommendations for improvements and resolve issues.


6. Conducts relevant research to assist with completing the appeals process and to stay informed on best practice and policy reforms. Coordinates interdepartmentally to share information, as needed.


7. Works with Utilization Review, Charge Auditor, and Coding team (hospital & professional) to resolve clinical denials and/or to formulate effective appeals.


8. Evaluates accounts for underpayment and/or undercharging. Appeals underpaid accounts to maximize correct reimbursement and recommends charge enhancements as appropriate for hospital and professional services.


9. Validates system build related to contracts and fee schedules. Regularly reviews work queues, accounts and/or reports to identify underpayments and take necessary steps needed to receive the full insurance allowable as per the contract.


10. Takes appropriate action to perform timely follow up to secure and collect balances. Uses and/or creates aging reports to do so, when necessary. Completes follow-up with patients to obtain additional information as needed.


11. Performs research and contacts ancillary department or reviews other available resources to resolve account balances. Accesses denied claims and queries for claims status identifying and addressing workflow issues that contribute to unpaid balances.


12. Supports billing staff by reviewing high-risk and/or high-dollar accounts before claim submission to prevent the possibility of a denial. Also, serves as an escalation point for issues identified by Senior Billers, Physician Billers, and Health Insurance Authorization & Denial Assistants (or other designee).


13. Performs other related duties as required. Utilizes new improvements and/or technology that relate to job assignment.