Denials Management Specialist
2 days ago
Req ID: 1680
Connext is a dedicated team of business process outsourcing experts and innovators, with experience in supporting world-class companies in Title and Escrow, Healthcare, Produce Distribution, Retail and Fashion, Design Consulting, and Finance.
We are currently looking for a Denials Management Specialist who will be working with Connext's Client in the United States of America.
What's in it for you?
- Competitive compensation
- Perfect Attendance Bonus
- Life insurance
- HMO Insurance
- Great company culture
- 25% Night Differential
- Annual Increase
- 25,000 Php Sign-On Bonus
- Work from Home
What is the job?
The Denials Management Specialist is responsible for auditing medical records on behalf of hospital clients to support denial reviews, defense audits, disallowed charge evaluations, and utilization reviews.
Responsibilities:
• Conducts comprehensive medical record audits to validate or defend charges and address patient or payer inquiries.
• Analyzes documentation using InterQual, MCG, and payer guidelines to determine medical necessity and care appropriateness.
• Prepares and supports clinical and contractual appeals, including RAC, CERT, ZPIC, SMRC, and avoidable LOS cases.
• Gathers and verifies supporting documentation and drafts detailed, compliant appeal letters.
• Manages multiple cases while ensuring accurate documentation in EMRs and client systems in accordance with HIPAA and regulatory standards.
• Maintains current knowledge of Medicare, Medicaid, and payer rules through ongoing training and best-practice updates.
Qualifications:
• At least three (3) years of clinical experience or equivalent work in auditing, Medicare appeals, utilization review, or denials management.
• Uses Microsoft Office, EMRs, and multiple systems effectively to support daily workflows.
• Reviews medical records and contributes to claims processing and clinical case management.
• Applies solid knowledge of Medicare/Medicaid rules and compliance requirements.
• Leverages bedside nursing experience to interpret complex clinical cases.
• Demonstrates strong attention to detail and accuracy in documentation and analysis.
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