Clinical Denial Management Specialist III

Clinical Denial Management Specialist III

With over 75 years of excellence in Dallas-Fort Worth, Texas, UT Southwestern is committed to excellence, innovation, teamwork, and compassion. As a world-renowned medical and research center, we strive to provide the best possible care, resources, and benefits for our valued employees. Ranked as the number 1 hospital in Dallas-Fort Worth according to U.S. News & World Report, we invest in you with opportunities for career growth and development to align with your future goals. Our highly competitive benefits package offers healthcare, PTO and paid holidays, on-site childcare, wage, merit increases and so much more. We invite you to be a part of the UT Southwestern team where you'll discover a culture of teamwork, professionalism, and a rewarding career!

The Revenue Cycle Department at UT Southwestern Medical Center has a new opportunity available for a Clinical Denial Management Specialist III. The successful candidate will work under moderate supervision to perform advanced level billing/denial responsibilities. The ideal applicant will have three (3) or more years of Clinical follow-up experience of complex minor and/or major surgical procedures. Preference given to applicants with experience in Surgical Oncology, Surgical Transplant, and Oral & Maxillofacial surgery. Clinical Follow up experience using EPIC is highly preferred. CPC certification is a plus.

Work from home (WFH): This will be a 100% WFH position. Preference given to candidates who live within fifty (50) miles of the DFW area. WFH details shall be discussed as part of the interview process. Shift: 8-hour semi-flex shift, Monday through Friday. The shift details shall be discussed as part of the interview process.

The duties for this position will include but not limited to the following areas of responsibility:

• Collections – Review and resolve accounts promptly per department guidelines.
• Review documentation – to review, research coding denials for minor/major surgical procedures and any related to E&M, CPT, Diagnosis, or modifier.
• Call insurance to obtain status update, to resolve complex denial and regarding reimbursement discrepancies.
• Create and submit appeals for clinical and coding denials in accordance with payer guidelines, supported by appropriate documentation.
• Review accuracy of payment posted to account, reconcile discrepancies, and make necessary adjustment based on Explanation of benefits.
• Resolve the discrepancy between insurance and billing.
• Identify and provide feedback on denial trends to leadership.
• Perform other duties as assigned by leadership.

UT Southwestern is proud to offer a competitive and comprehensive benefits package to eligible employees. Our benefits are designed to support your overall wellbeing, and include:

• PPO medical plan, available day one at no cost for full-time employee-only coverage
• 100% coverage for preventive healthcare-no copay
• Paid Time Off, available day one
• Retirement Programs through the Teacher Retirement System of Texas (TRS)
• Paid Parental Leave Benefit
• Wellness programs
• Tuition Reimbursement
• Public Service Loan Forgiveness (PSLF) Qualified Employer

Learn more about these and other UTSW employee benefits!

Required Education: High School Diploma Or equivalent or Experience 3 years medical billing or collections experience.

Must demonstrate the ability to work clinical denials for complex E&M services, diagnostic studies, and/or minor surgical procedures and Must demonstrate a strong knowledge of medical claims recovery and/or collections rules and regulations

Preferred Education: Coding certifications (CPC, CPMA, CMC, ART, RRA, RHIA, RHIT, CCS, CCA) and/or degrees (associate level, bachelor level, master level) are preferred and may be considered in lieu of experience.

Licenses and Certifications: (CPC) CERT PROFESSIONAL CODER Upon Hire or (CPMA) Cert Prof Medical Auditor Upon Hire or (CMC) CERT MEDICAL CODER Upon Hire or (ART) ASSOC RECORDS ADMIN Upon Hire or (RRA) REGISTERED RECORDS ADMIN Upon Hire or (RHIA) REGD HEALTH INFO ADMINIST Upon Hire or (RHIT) REGD HEALTH INFO TECHNOLO Upon Hire or (CCS) CERT CODING SPECIALIST Upon Hire or (CCA) Cert Coding Associate Upon Hire

Job Duties: Review, research and resolve coding denials for complex diagnostic studies, endoscopic, interventional and/or major surgical procedures. This includes denials related to the billed E&M, CPT, diagnosis, and modifier. Denial types could include bundling, concurrent care, frequency and limited coverage. Prepare and submit claim appeals, based on payor guidelines, on complex coding denials. Identify denial, payment, and coding trends in an effort to decrease denials and maximize collections. Contact payers, via website, phone and/or correspondence, regarding reimbursement of claims denied for coding related reasons. Interpret Managed Care contracts and/or Medicare and Medicaid rules and regulations to ensure proper reimbursement/collection. Requires knowledge of carrier specific claim appeal guidelines. This includes Claim Logic, internet, and paper/fax processes. Requires proven analytical, and decision making skills to determine what selective clinical information must be submitted to properly appeal the denial. Requires proven knowledge of CPT and ICD-10 coverage policies, internal revenue cycle coding processes and the billing practices of the specialty service line. This position requires clear and concise written and oral communication with payors, providers, and billing staff to insure resolution of complex coding denials. Requires the ability to read and interpret E&M notes, complex diagnostic study results, endoscopic and interventional results and/or major surgical operative notes. Based on the documentation review, confirm or change the billed CPT code(s), diagnosis code(s) and modifiers (if applicable) in order to attain denial resolution. Requires proven knowledge of the specialty specific service line documentation requirements. Must be familiar with the Medicare and Medicaid teaching physician documentation billing rules within 60 days of hire. Serves as a resource to the FERC Team Leads, Compliance Auditors, Medical Collectors and MSRDP Clinical Denials Management Specialist I & II. Requires a billing and coding knowledge level that provides guidance on and resolution to resolve claim denials and rejections. Makes necessary adjustments as required by plan reimbursement. Duties performed may include one or more of the following core functions: (a) Directly interacting with or caring for patients; (b) Directly interacting with or caring for human-subjects research participants; (c) Regularly maintaining, modifying, releasing or similarly affecting patient records (including patient financial records); or (d) Regularly maintaining, modifying, releasing or similarly affecting human-subjects research records. Performs other duties as assigned.

Security This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information.

EEO UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. As an equal opportunity employer, UT Southwestern prohibits unlawful discrimination, including discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status.