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Clinical Denial Management Specialist II

Job Number: 79262
Categories: Insurance/Billing
Location: 5323 Harry Hines Blvd, Dallas, TX
Department: 713007 - MG Rev Cyc-Surg Follow-Up
Full/Part Time/PRN: Day Job
Regular/Temporary: Regular


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


Salary Negotiable

Experience and Education

High School diploma or equivalent; Associates degree preferred. Four (4) years medical billing or collections experience. Six (6) months must include denials management and proven knowledge of billing/coding guidelines for complex E&M services, diagnostic studies, and/or minor surgical procedures that encompasses CPT and ICD-10 codes, modifiers, and payer specific billing rules. Work requires experience in Medical Billing, Accounts Receivables, and/or Collections within a healthcare or insurance environment. Work requires knowledge of CMS 1500, ICD-10, and CPT coding. Requires working knowledge of Epic Resolute.

Job Duties

1.Review, research and resolve coding denials for E&M services, diagnostic studies, and minor 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 moderate complexity coding denials. Identify denial, payment, and coding trends in an effort to decrease denials and maximize collections.
2.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.
3.Requires knowledge of carrier specific claim appeal guidelines. This includes Claim Logic, internet, and or 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 moderate complex coding denials.
4.Read and interpret E&M notes, diagnostic study results and or minor procedure 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.
5.Makes necessary adjustments as required by plan reimbursement.
6.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.

**Other Duties: Performs other duties as assigned.

UTSouthwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. In accordance with federal and state law, the University prohibits unlawful discrimination, including harassment, on the basis of: race; color; religion; national origin; sex; including sexual harassment; age; disability; genetic information; citizenship status; and protected veteran status. In addition, it is UTSouthwestern policy to prohibit discrimination on the basis of sexual orientation, gender identity, or gender expression.

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