Denials Specialist - Remote

JOB SUMMARY Responsible for validating dispute reasons following Explanation of Benefits (EOB) review, escalating payment variance trends or issues to NIC management, and generating appeals for denied or underpaid claims. ESSENTIAL DUTIES AND RESPONSIBILITIES Include the following. Others may be assigned. Validate denial reasons and ensures coding in DCM is accurate and reflects the denial reasons. Coordinate with the Clinical Resource Center (CRC) for clinical consultations or account referrals when necessary, Generate an appeal based on the dispute reason and contract terms specific to the payor. This includes online reconsiderations. Follow specific payer guidelines for appeals submisson Escalate exhausted appeal efforts for resolution Work payer projects as directed Research contract terms/interpretation and compile necessary supporting documentation for appeals, Terms & Conditions for Internet enabled Managed Care System (IMaCS) adjudication issues, and referral to refund unit on overpayments. Perform research and makes determination of corrective actions and takes appropriate steps to code the DCM system and route account appropriately. Escalate denial or payment variance tr…