Medical Billing Denial Specialist

Company & Position Summary:

Critical Care, Pulmonary and Sleep Associates is a multispecialty private physician practice, providing Critical Care, Pulmonary and Sleep medical services to the Denver metro area for over 40 years. Our dedicated team of Board-Certified Critical Care, Pulmonary and Sleep Physicians along with our skilled clinical and administrative staff exclusively serve nine Common Spirit and AdventHealth Hospital ICU’s and multiple outpatient clinic locations spanning Colorado’s front range. CCPSA’s organizational culture exemplifies excellence in patient centered care, unified teamwork, and a highly collaborative approach in all business and clinical operations.  We are currently seeking a Medical Billing Denial Specialist to join our committed team of professionals.

The Medical Billing Denial Specialist is responsible for analyzing and resolving insurance claim denials for Critical Care, Pulmonary and Sleep Associates providers. This role uses coding, contract, medical record, and payer-policy research to prepare appeals, recover reimbursement on incorrectly denied claims, identify recurring denial trends, and escalate unresolved issues. The specialist will also communicate payer policy changes, supports team education, and will collaborate on projects assigned by the manager.

Essential Responsibilities and Tasks:

- Reviews denied claims to verify billing and coding accuracy, routes necessary corrections to the appropriate coding queue and submits appeals or reconsiderations to payers as appropriate.

- Reviews denials to identify trends or patterns, communicates findings, and helps identify opportunities to prevent recurring errors.

- Collaborates with coders, the Revenue Cycle Operations Manager, and other team members to resolve coding, billing, and charge-related questions.

- Maintains knowledge of applicable compliance requirements and changing regulatory guidelines.

- Applies knowledge of coding and medical terminology to evaluate claim denials and determine when an appeal or reconsideration is appropriate.

- Supports and participates in process and quality improvement initiatives.

- Achieve goals set forth by supervisor regarding error-free work, transactions, processes and compliance requirements.

- Provides exceptional customer service by responding promptly to patient, insurance, internal, and external inquiries; proactively resolving issues; documenting outcomes clearly; and tracking requests through completion.

- Identifies missing payments and overpayments, analyzes account credits and routes accounts to the appropriate follow-up queues as needed.

- Other duties as assigned by the manager.

Skills, Education and/or Work Experience Requirements:

- Minimum of 2-3 years of hands-on experience in a medical billing department with strong AR denial follow-up, appeals, and coding knowledge is required.

- Demonstrate strong understanding of payer websites and appeal process by all payers including commercial and government payers including VA, Tricare, Medicare, Medicaid, and Medicare Advantage plans.

- Demonstrate knowledge of and experience in Professional Medical Billing, claims processing, follow-up and appeals are required.

- Extensive knowledge on use of email, search engine, Internet; ability to effectively use payer websites; knowledge and use of Microsoft Products: Outlook, Word & Excel.

- Strong reasoning, critical thinking, analytical and mathematical skills.

- Ability to work independently, flexibly shifting from big picture to detailed tasks, with high productivity, and regularly execute deadlines.

- EPIC EHR with Resolute Professional Billing module working knowledge and experience a strong preference but not required.

- High School Diploma or GED required.

C ompensation:

- Competitive hourly pay.

- Benefits effective date-of-hire (no waiting period).

- Comprehensive medical benefits. Company covers 80-85% percent of individual or family premium.

- Dental and vision benefits offered at no cost to the employee. Company covers 100% of individual or family premium.

- Life and AD&D benefits.

- Optional additional life & disability insurance at group discounts.

- PTO and holiday pay.

- 401k benefits with company contribution after eligibility period.

- Position reports to Revenue Cycle Operations Manager.