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Tenet Healthcare Denials Specialist - Remote in Frisco, Texas

As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

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 ANDRESPONSIBILITIES

Include thefollowing. Others may be assigned.

  • Validate denial reasons and ensurescoding 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 disputereason and contract terms specific to the payor. This includes onlinereconsiderations.

  • Follow specific payer guidelines forappeals submission

  • Escalate exhausted appeal efforts forresolution

  • Work payer projects as directed

  • Research contract terms/interpretationand compile necessary supporting documentation for appeals, Terms &Conditions for Internet enabled Managed Care System (IMaCS) adjudicationissues, and referral to refund unit on overpayments.

  • Perform research and makes determinationof corrective actions and takes appropriate steps to code the DCM system androute account appropriately.

  • Escalate denial or payment variancetrends to NIC leadership team for payor escalation.

KNOWLEDGE, SKILLS, ABILITIES

To perform this jobsuccessfully, an individual must be able to perform each essential dutysatisfactorily. The requirements listed below are representative of theknowledge, skill and/or ability required. Reasonable accommodations may be madeto enable individuals with disabilities to perform the essential functions.

  • Intermediate understanding ofExplanation of Benefits form (EOB), Managed Care Contracts, Contract Languageand Federal and State Requirements

  • Intermediate knowledge of hospital billingform requirements (UB-04)

  • Intermediate understanding of ICD-9,HCPCS/CPT coding and medical terminology

  • Intermediate Microsoft Office (Word,Excel) skills

  • Advanced business letter writing skillsto include correct use of grammar and punctuation.

EDUCATION /EXPERIENCE

Include minimumeducation, technical training, and/or experience preferred to perform the job.

  • High School Diploma or equivalent, somecollege coursework preferred

  • 3 - 5 years of experience in a hospitalbusiness environment performing billing and/or collections

PHYSICAL DEMANDS

The physical demandsdescribed here are representative of those that must be met by an employee tosuccessfully perform the essential functions of this job. Reasonableaccommodations may be made to enable individuals with disabilities to performthe essential functions.

  • Ability to sit and work at a computerterminal for extended periods of time

WORK ENVIRONMENT

The work environmentcharacteristics described here are representative of those an employeeencounters while performing the essential functions of this job. Reasonableaccommodations may be made to enable individuals with disabilities to performthe essential functions.

  • Call Center environment with multipleworkstations in close proximity

Job: Conifer Health Solutions

Organization:

Title: Denials Specialist - Remote

Location: TX-Frisco

Requisition ID: 2005040203

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