Denials Management Follow Up Representative

Accountabilities: Denials & Appeals Follow-Up: Coordinate denial and appeal follow-up activities to ensure third-party payors respond promptly and process outstanding institutional and professional claims, documentation requests, and appeals appropriately. Insurance Payor Communication: Contact insurance carriers to investigate outstanding appeals, clarify payment decisions, resolve reimbursement issues, and facilitate the collection of amounts owed following successful appeals. Workflow Coordination: Monitor daily denial management and appeal follow-up activities, collaborate with relevant stakeholders, and ensure outstanding items receive timely attention. Tracking System Administration: Maintain the denial management tracking application, including activity records, user access, software updates, and end-user training to support consistent follow-up processes. Reporting & Performance Analysis: Collect, organize, and analyze information from multiple systems to produce regular status reports, performance metrics, and trend analyses for designated stakeholder groups. Documentation & Record Management: Maintain complete, accurate, and easily retrievable records of denial activity, appeal submissions, payor responses, and follow-up actions to support efficient case management. Committee & Review Support: Coordinate denial-related review activities and prepare supporting documentation, analytical reports, and other materials for committee meetings. Revenue Integrity Projects: Support departmental initiatives by coordinating meetings, researching insurance payor criteria, preparing documentation, and contributing to process improvement activities. Compliance & Payment Accuracy: Apply knowledge of insurance billing requirements, reimbursement methodologies, coding standards, and government and managed care payment policies to support accurate claims resolution. Cross-Functional Collaboration: Communicate clearly with internal teams and external payors, helping resolve issues, share relevant information, and maintain high standards of service and work quality. Requirements Professional Experience: 5–7 years of experience in a healthcare patient accounting or revenue cycle environment, with practical knowledge of hospital billing, denials, appeals, and reimbursement processes. Education: Bachelor's degree or an equivalent combination of education and relevant professional experience. Revenue Cycle Expertise: Strong understanding of hospital revenue cycle management, including electronic data interchange (EDI) transaction sets such as 837I and 837P, insurance contract rates, reimbursement terms, registration, and collections. Claims & Payment Knowledge: Understanding of government and managed care billing requirements, insurance coverage policies, payment rules, and reimbursement procedures. Remittance Interpretation: Ability to interpret electronic and paper Explanation of Benefits (EOB) documents and payor 835 remittance advice responses to investigate claim outcomes and identify payment discrepancies. Medical Coding & Billing: Familiarity with Correct Coding Initiative (CCI) edits, Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), ICD-10 diagnosis codes, and revenue codes. Healthcare Technology: Experience using Epic electronic medical record systems, particularly Hospital Billing (HB) and/or Professional Billing (PB) modules. Data Management & Reporting: Ability to maintain accurate tracking records, consolidate information from multiple systems, analyze performance metrics, and prepare clear, actionable reports. Organization & Attention to Detail: Strong organizational skills and the ability to manage multiple cases, documentation requirements, deadlines, and follow-up priorities while maintaining accurate records. Communication & Collaboration: Excellent written and verbal communication skills, with the ability to coordinate effectively with insurance representatives, internal departments, and cross-functional stakeholders. Problem-Solving & Accountability: Strong analytical skills, initiative, and a commitment to resolving payment issues, improving workflows, and delivering consistently high-quality work. Preferred Experience: At least 3 years of experience in hospital third-party collections or accounts receivable management is preferred. Remote Work Readiness: Ability to work independently, manage priorities, and collaborate effectively in a fully remote environment. Benefits Remote Work: Fully remote position based in the United States. Full-Time Employment: Stable, full-time opportunity within a healthcare organization focused on patient care, research, and operational excellence. Comprehensive Healthcare Coverage: Eligible employees receive medical, dental, and vision insurance. Retirement Benefits: Retirement savings plan with employer matching, subject to applicable plan terms. Tuition Assistance: Educational support to encourage professional development and continued learning. Meaningful Work: Contribute to the financial operations supporting specialized pediatric healthcare and services for children and their families. Professional Development: Opportunity to deepen expertise in hospital revenue cycle management, denial resolution, insurance reimbursement, and revenue integrity. Collaborative Environment: Work with healthcare professionals and operational teams committed to quality, accountability, innovation, and continuous improvement. Experience-Based Compensation: Compensation is determined according to relevant professional experience and internal departmental equity. A specific salary range was not provided in the available job description.