Denials Management Specialist - Remote - 139698

UC San Diego Health's Revenue Cycle department supports the organization's mission to deliver outstanding patient care and to create a healthier world - one life at a time. We are a diverse, patient-focused, high-performing team with a commitment to quality, collaboration, and continuous improvement that enables us to deliver the maximum standard of care to our patients. We offer challenging career opportunities in a fast-paced and innovative environment and we embrace individuals who demonstrate a deep passion for problem-solving and customer service. improvement that enables us to deliver the maximum standard of care to our patients. We offer challenging career opportunities in a fast-paced and innovative environment and we embrace individuals who demonstrate a deep passion for problem-solving and customer service.

This position supports essential facility revenue cycle operations with primary focus on denials resolution, payer follow-up, reimbursement recovery, and account receivable reduction. The role is responsible for researching denied accounts, identifying root causes, resolving payer barriers, submitting appeals or reconsiderations when appropriate and escalating complex issues that requiring coding, clinical, billing, contract, or payer intervention. Current productivity and account resolution metrics reflect approximately $3+ million in monthly net cash collections and $13.3 million in gross cash account receivable resolution.

• Minimum of 4 years of recent healthcare revenue cycle experience, preferably in hospital/facility billing, payer follow-up, collections, denials, or account resolution including experience researching and resolving denied, unpaid, or underpaid healthcare claims.

• HFMA Certified Revenue Cycle Representative (CRCR) required or within 120 days of employment.

• Experience with hospital billing and collections, including specialty billing, reimbursement follow up, denial and claim rejection trending and follow up.

• Expert knowledge of medical insurance and State and Federal rules and regulations related to billing Insurance Claims.

• Knowledge of accounting and cash handling principles and various billing documents and claim forms.

• Extensive knowledge in Insurance claims appeals with extensive experience in use and understanding of coding as well as demonstration of coding guidelines including medical and surgical terminology.

• Excellent verbal and written communication skills and able to promote and maintain superb communication in the following relationships: peer to peer, management, third party payors, patients and departments within UCSD.

• Must demonstrate reliability, communicate constructively, actively listen, function as an active participant, share openly and willingly, cooperate and pitch in to help, exhibit flexibility, show commitment to the team(s), work as a problem-solver, and treat others in a respectful, professional and supportive manner.

• Expertise using Excel, Word and Outlook.

• Knowledge of home infusion and pharmacy billing with strong knowledge base of Specialty Infusion billing.

• A self-starter who is accountable and requires minimal direction and supervision; a person who is open to new ideas; and a creative and flexible individual who is comfortable working in a large, complex organization.

• Working knowledge of payer follow-up, claim status research, remittance review, payer correspondence, and account documentation.

• Ability to interpret denial reason codes, remittance activity, payer responses, and claim status information to determine appropriate next steps.

• Demonstrated ability to manage high-volume/high dollar account work while maintaining accuracy, productivity, and compliance.

• Recent acute care hospital/facility denials resolution experience.

• Recent Epic HB Resolute experience supporting hospital billing, payer follow-up, denials

• Knowledge of UB-04/CMS-1450 facility claim requirements, including bill type, condition codes, occurrence codes, value codes, revenue codes, HCPCS/CPT codes, modifiers, diagnosis codes, and payer-specific billing requirements.

• Understanding of the relationship between revenue codes, HCPCS/CPT codes, modifiers, diagnosis codes, authorizations, and facility reimbursement.

• Experience resolving facility denials related to authorization, medical necessity, coding, billing edits, timely filing, eligibility, coordination of benefits, payer processing, reimbursement disputes, and underpayments.

• Ability to distinguish between clinical denials and technical/administrative denials and determine the appropriate resolution pathway, including clinical review, coding review, authorization follow-up, corrected claim, payer escalation, or administrative appeal action.

• Experience submitting or supporting appeals, reconsiderations, corrected claims, payer portal disputes, and medical record submissions.

• Strong critical thinking skills with the ability to identify denial root causes, determine appropriate account resolution pathways, and escalate recurring denial trends.

• Familiarity with CARC/RARC codes, remittance advice, payer correspondence, and claim adjustment logic.

• Understanding of facility reimbursement concepts such as DRG, per diem, percent of charges, case rates, carve-outs, bundled services, and payer contract/payment methodology basics.

• Experience collaborating with billing, coding, revenue integrity, patient access, utilization management, clinical appeals, contracting, or payer representatives to resolve complex denials.

• Must be able to work various hours and locations based on business needs.

• Employment is subject to a criminal background check and pre-employment physical.