SME - Denial Management

Designation: SME - Denial Management

Experience: 2-3 years

Skills desired:

• Detailed knowledge of US healthcare billing cycle
• Experience working with different EMR/EHR systems like Epic, Cerner, Allscripts, Athenahealth, NextGen, eClinicalWorks, Meditech, etc.

• Denial analysis and management

  - Review and analyze denied insurance claims to identify cause of denials such as coding issues, preauthorization, payer-specific policies - Develop and track denial log to monitor patterns and trends in denied claims - Experience talking with payers to obtain clarification with denials and initiate timely appeals when appropriate
• Expertise in working with denial reason codes (CARC, RARC) and identifying root causes of denials.
• Strong understanding of billing regulations, CPT, ICD-10, HCPCS codes, and compliance standards (HIPAA, CMS guidelines).

• Appeals

  - - Understand 1st, 2nd, 3rd, and External Level Appeal process, system, and documentation SOP - Prepare, submit, and follow up on appeals ensuring all necessary documentation is included - Revie Review assigned denials and EOBs for appeal filing information. Gather any missing information - Review case history, payer history, and state requirements to determine appeal strategy - Obtain patient and/or physician consent and medical records when required by the insurance plan or state - Gather and fill out all special appeal or review forms - Create appeal letters, attach the materials referenced in the letter, and mail them

• Maintain a record of all appeals and responses to track appeal outcomes and recovery rates
• Monitor payer response timelines to ensure appeal filing deadlines are met
• Track insurance company and state requirements and denial trend changes