Denial Resolution Coordinator

About Us

All Care To You is a Management Service Organization providing our clients with healthcare administrative support. We provide services to Independent Physician Associations, TPAs, and Fiscal Intermediary clients.  ACTY is a modern growing company which encourages diverse perspectives. We celebrate curiosity, initiative, drive and passion for making a difference. We support a culture focused on teamwork, support, and inclusion. Our company is fully remote and offers a flexible work environment as well as schedules. ACTY offers 100% employer paid medical, vision, dental, and life coverage for our employees.  We also offer paid holiday, sick time, and vacation time as well as a 410k plan.  Additional employees paid coverage options available.

Job purpose

The Denial Resolution Coordinator is responsible for working with healthcare providers and their billing teams to resolve denied or underpaid claims for professional services. This role ensures timely and accurate resolution of appeals and reconsiderations, helping maintain client satisfaction and financial stability. The position plays a key role in maintaining client satisfaction, providing critical support to ensure the financial health of our clients and growth for our company. Strong written and verbal communication skills are essential for interacting with clients and insurance representatives.

Duties and responsibilities

Claims Management:

Evaluate provider appeal requests using industry coding standards, health plan reimbursement guidelines, and billing regulations to determine if they are appropriate

Submit robust appeals and reconsiderations to the health plan in accordance with their guidelines, providing adequate justification to substantiate the appeal.

Provide feedback to providers when an appeal request is denied, providing justification for the decision.

Follow up on submitted appeals to ensure prompt processing.

Provide determination details to the provider, obtaining and providing determination letters when available.

Review correspondence related to denials and take appropriate action based on the content of the letter.

Follow up with insurance carriers, providers, or other stakeholders to gather additional information or documentation required for claims resolution.

Monitor incoming messages from providers and respond to the provider or escalate the request to the appropriate team member.

Assist with special claims research projects as assigned.

All other duties as assigned.

Communication:

Communicate effectively with insurance companies, healthcare providers, and their billing staff to resolve claims issues and answer inquiries.

Document all interactions and updates in the claims management system.

Documentation and Reporting:

Maintain accurate records of claim status, actions taken, and resolutions utilizing established policies and procedures.

Prepare and submit reports on claim follow-up activities and status updates to management as requested.

Compliance:

Ensure all claims follow-up activities comply with company policies, industry regulations, and legal requirements.

Stay updated on changes in insurance policies, regulations, and industry standards.

Attend departmental and company meetings as required.

Problem Resolution:

Identify and report trends which could have an overall negative impact on claim payments such as processing errors, denials, or billing issues.

Investigate and resolve discrepancies or issues related to claims processing and payment.

Work with other team members and departments ensure proper claim submission.

Continuous Improvement:

Identify and recommend process improvements to enhance the efficiency and effectiveness of the claims follow-up process.

Participate in training and development opportunities to stay current with best practices and industry trends.

Qualifications                                

A minimum of 8 years’ experience as a medical biller or similar role, with at least 3 years in denials and appeals.

Excellent technical skills including the ability to work in multiple systems simultaneously and learn new systems quickly.

EZ-Cap experience preferred.

Electronic Data Interchange (EDI) Clearinghouse (Office Ally) experience preferred.

Microsoft Suite – Outlook, Teams, Office365, OneNote, OneDrive, SharePoint

Sequel Server Management Studio

Confluence

Azure

Advanced knowledge of CPT Codes, ICD-10 Codes, Modifiers, MUE, LCD, NCD, and CCI edits.

Clear understanding of health plan reconsideration and appeal guidelines and rules.

Thorough knowledge of healthcare benefits, network participation, coordination of benefits, referral and authorization requirements, and insurance follow up.

Must have strong time management skills, be able to multi-task, resolve problems utilizing critical thinking, be detail oriented and highly organized.

Ability to work in a fast-paced environment while maintaining strict confidentiality.

Excellent written and verbal communication skills.