Denial Appeals Specialist

Analyzes, investigates, and resolves claims and billing information errors associated with inpatient and outpatient Medicaid claims. Ensures compliance with Medicaid guidelines and Memorial Medical Center organizational policies while supporting efficient, accurate reimbursement processing.

Responsibilities

• Utilize electronic software to determine Medicaid insurance eligibility and coverage for inpatient and outpatient claims.
• Review daily claim listings and determine which require further analysis and action.
• Investigate incomplete or incorrect claims information and resolve errors to ensure Medicaid-compliant submissions.
• Prioritize claims, file them electronically, and follow up to support timely reimbursement.
• Research unpaid items and contact patients, guarantors, or other third-party payment sources to secure payment arrangements.
• Review Medicaid claim denials and prepare appeal documentation as needed.
• Research correspondence related to Medicaid payments and claims and provide supporting background information.
• Resolve complex Medicaid account issues and report problematic trends to management when appropriate.
• Analyze rejected account reports and determine reasons for rejection.
• Provide input on system edits that support accurate and compliant Medicaid claim processing.
• Respond to internal requests regarding coding, billing, and processing of Medicaid claims.
• Communicate with internal and external stakeholders to resolve Medicaid claim issues.
• Make corrections to charges and contractual allowances within scope of authority.
• Identify and calculate write-off amounts and obtain required management approvals.
• Document claim and payment status in online systems and electronic files.
• Maintain compliance with Medicaid policy guidelines and organizational procedures.
• Cross-train on other unit duties and serve as backup support when needed.