Director of Denial Management
Sun Mar Healthcare Sun Mar Healthcare Brea, CA Brea, CA Full-time Full-time From $140,000 a year From $140,000 a year 6 days ago 6 days ago 6 days ago The Denial Management Specialist is responsible for the optimal payment of claims from Medicare, Medicaid, Manage Care Plans and any other contracted insurance carriers.
Primary duties include, but are not limited to:
Responsible for managing all deferrals and or denials by conducting a comprehensive review of clinical documentation, clinical criteria/guideline, policy, and or EOC/benefit policy Apply clinical knowledge when processing all deferrals and or denials, supported by clinical criteria Follow up on unpaid, underpaid & denied claims utilizing monthly aging reports, filing appeals when appropriate to obtain maximum reimbursement and establish and maintain strong relationships with providers, clients and fellow staff, monitor trend in denials of payment changes Investigates insurance denials and identifies and implements best recommended action and coordinates with facilities as needed Solves billing questions/problems and audits patient accounts Understands and adheres to each insurance carrier's claim submission guidelines Determines need for payer appeal and sends individual appeal letters Monitors appeals for resolution Conducts insurance negotiation for non-par payments Access denied claims from the worklist and queries claim status with the payor, utilizing all appropriate systems, websites to effectively research the claim and resubmit or appeal as necessary Makes necessary arrangements for medical records requests, completion of additional information requests etc.
as requested by insurance companies to ensure timely resolution of outstanding denied/unpaid claims Prioritizes claims based on aging and outstanding dollar amounts, or as directed by management Regularly meets with facility management to review challenges or billing obstacles as well as to provide status of outstanding ageing reports worked
Qualifications:
Possession of an active, unrestricted, and current California Registered Nurse (RN) or Licensed Vocational Nurse (LVN) license A minimum of five years utilization management experience Must be an expert with Patient Driven Payment Model (PDPM) Demonstrated knowledge of payor criteria Proficient in Microsoft Office applications Strong written and oral communication skills Job Type:
Full-time Pay:
From $140,000.
00 per year
Benefits:
401(k) Dental insurance Health insurance Paid time off Vision insurance Schedule:
Day shift Monday to Friday Ability to commute/relocate:
Brea, CA 92821:
Reliably commute or planning to relocate before starting work (Required) Application Question(s):
Are you proficient with the Patient-Driven Payment Model (PDPM)?
Experience:
Utilization management:
5 years (Required) Medicare:
2 years (Required) License/Certification:
RN/LVN License (Required) Work Location:
In person.
Estimated Salary: $20 to $28 per hour based on qualifications.
Primary duties include, but are not limited to:
Responsible for managing all deferrals and or denials by conducting a comprehensive review of clinical documentation, clinical criteria/guideline, policy, and or EOC/benefit policy Apply clinical knowledge when processing all deferrals and or denials, supported by clinical criteria Follow up on unpaid, underpaid & denied claims utilizing monthly aging reports, filing appeals when appropriate to obtain maximum reimbursement and establish and maintain strong relationships with providers, clients and fellow staff, monitor trend in denials of payment changes Investigates insurance denials and identifies and implements best recommended action and coordinates with facilities as needed Solves billing questions/problems and audits patient accounts Understands and adheres to each insurance carrier's claim submission guidelines Determines need for payer appeal and sends individual appeal letters Monitors appeals for resolution Conducts insurance negotiation for non-par payments Access denied claims from the worklist and queries claim status with the payor, utilizing all appropriate systems, websites to effectively research the claim and resubmit or appeal as necessary Makes necessary arrangements for medical records requests, completion of additional information requests etc.
as requested by insurance companies to ensure timely resolution of outstanding denied/unpaid claims Prioritizes claims based on aging and outstanding dollar amounts, or as directed by management Regularly meets with facility management to review challenges or billing obstacles as well as to provide status of outstanding ageing reports worked
Qualifications:
Possession of an active, unrestricted, and current California Registered Nurse (RN) or Licensed Vocational Nurse (LVN) license A minimum of five years utilization management experience Must be an expert with Patient Driven Payment Model (PDPM) Demonstrated knowledge of payor criteria Proficient in Microsoft Office applications Strong written and oral communication skills Job Type:
Full-time Pay:
From $140,000.
00 per year
Benefits:
401(k) Dental insurance Health insurance Paid time off Vision insurance Schedule:
Day shift Monday to Friday Ability to commute/relocate:
Brea, CA 92821:
Reliably commute or planning to relocate before starting work (Required) Application Question(s):
Are you proficient with the Patient-Driven Payment Model (PDPM)?
Experience:
Utilization management:
5 years (Required) Medicare:
2 years (Required) License/Certification:
RN/LVN License (Required) Work Location:
In person.
Estimated Salary: $20 to $28 per hour based on qualifications.
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