Prof Fee Coding Denial Specialist

ID 2021-4583
Professional Fee Billing
Work Location
Division : Name
Department : Name
SW-Pro Fee Billing
Position Sub-Category
Position Type
Full Time
Employment Type
Work Hours
Provider Schedule (specific schedule)
Monday-Friday, 8:00 AM - 5:00 PM
On call Required
Sub Category


Responsible for resolution of all third party payer rejections. Must be able to determine root cause of rejections and determine necessary ?next steps? required to resolve error. Must be familiar with follow up processes such as claim correction, appeal processes for third-party payers, electronic claim resubmission processes and calling payers to resolve to investigate denials. Must be able to effectively communicate with other departments such as Coding, Patient Accounting, and Customer Service as needed to resolve issues with accounts.


Talent Pool: Corporate Services/Professional



  • Denial Resolution - Ensure assigned coding denial workqueues have edits resolved in a timely manner. Identifies trends within the systenm prohibiting successful claim submission and communicate to Pro Fee Business Liaison, Pro Fee Manager and Information Systems. Assures timely and accurate resubmission of denied claims to third party payers via electronic and paper claim resubmissions. Assures timely response to thrid party payers' request for additional information in addition to following up on denied claims. Assures timely implentation of appeals when needed and diligently follow up with third party payer until resolution is received.
  • Communication - Provides communication from the billing and follow-up functions as to incomplete or inacurate information resulting from the front-end back functions to Pro Fee Business Liasion, Pro Fee Leadership and Information Systems for resolution. Record actions and findings while trying to resolve denials in billing system via account notes. Must be able to effectively communicate with other departments to ensure proper account resolution is achieved. Must be able to effectively communicate with third-party payers indentified issues and trends to resolve denials and identify how to prevent future denials.
  • Business Office Support - Provides support for other departments such as Customer Service, Cash Management, Financial Counseling by providing information to resolve questions on patient accounts. Provides support as needed to vendors regarding questions to resolve patient account issues. Work closely with IT Partners in the maintenance and monitoring of coding interfaces such as OPTUM systems.
  • Compliance - Ensures that Revenue Cycle services are provided in accordance with the State and Federal regulations, organizational policy, and accreditation/compliance requirements. Maintains compliance to all regulatory requirements/law as they relate to responsibilities (Corporate Compliance, HIPPA, etc.). Remains current through education, in-services, etc.



Required: Associate's Degree and Coding Certification

Preferred: RHIT or RHIA



Coding Certification.

Must be able to efficiently navigate billing system, payer website and any vendor software used in denial management.
Proficient in Word, Excel and Power Point.



Required: Coding Certification - must be maintained.



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