The Denials Analyst is responsible for analyzing, managing, and resolving denied claims at Riverside Healthcare. This role involves reviewing denied claims to identify root causes, developing strategies to address and appeal denials, and implementing process improvements to reduce the frequency of denials. The Denials Analyst works closely with billing, coding, and revenue cycle teams to ensure accurate and timely claim resolution. The role requires strong analytical skills, a deep understanding of payer policies, and effective communication skills to interact with insurance companies and internal stakeholders.

Essential Duties

• Review and analyze denied claims to determine the reason for denial and potential for resolution.
• Identify patterns and root causes of claim denials to develop effective corrective actions and prevent future issues.
• Collaborate with billing and coding teams to gather necessary documentation and information for appeals.
• Develop and submit appeal letters to insurance companies, utilizing accurate data and thorough explanations to support claim adjustments.
• Monitor and track the status of denied claims and appeals, ensuring timely follow-up and resolution.
• Maintain detailed records of denial trends, appeal outcomes, and related activities for reporting and analysis.
• Work with payer representatives to negotiate settlements and resolve complex denial issues.
• Provide recommendations for process improvements to enhance claim submission accuracy and reduce denial rates.
• Stay informed about changes in payer policies, coding guidelines, and industry regulations that may impact claim denials and resolution

Non-essential Duties

• Assist with special projects related to revenue cycle management and claim denial prevention.
• Participate in training sessions and workshops to stay updated on best practices and industry standards.
• Support cross-functional teams with ad-hoc reporting and data analysis as needed.

Preferred Experience

• 2+ years of experience in claims management, denial analysis, or revenue cycle operations within a healthcare setting.
• Strong knowledge of payer policies, medical coding (ICD, CPT, HCPCS), and healthcare reimbursement processes.
• Excellent analytical and problem-solving skills with a keen attention to detail.
• Proficiency in using claims management software and electronic health records (Epic experience preferred).
• Strong communication skills, both written and verbal, with the ability to interact effectively with insurance companies and internal teams.
• Ability to work independently, prioritize tasks, and manage multiple projects in a fast-paced environment.

Required Licensure/Education

• High school diploma or equivalent required.

Preferred Education

• Bachelor’s degree in Healthcare Administration, Business, Finance, or a related field preferred.

Employee Health Requirements

Employee Health Requirements
Exposure to:
Chemicals: None
Video Display Terminals: Extreme
Blood and Body Fluids: None
TB or Airborne Pathogens: None
Sensory requirements (speech, vision, smell, hearing, touch):
Speech: Needed for presentations/training, telephone communication, facilitate meetings.
Vision: Needed to read memos and literature.
Smell: N/A
Hearing: Needed for telephone communications, meetings, and listening to employee concerns.
Touch: Need to write, do computer entry, filing.
Activity/Lifting Requirements
Average Hours per Week: 40
Shift: Days
Percentage of time during the normal workday the employee is required to: Sit: 85% Twist: 0% Stand: 5% Crawl: 0% Walk: 5% Kneel: 0% Lift: 2% Drive: 0% Squat: 1% Climb: 0% Bend: 1% Reach above shoulders: 1%
The weight required to be lifted each normal workday according to the continuum described below:
Up to 10 lbs: Occasionally
Up to 20 lbs: Occasionally
Up to 35 lbs: Not Required
Up to 50 lbs: Not Required
Up to 75 lbs: Not Required
Up to 100 lbs: Not Required
Over 100 lbs: Not Required
Describe and explain the lifting and carrying requirements. (Example: the distance material is carried; how high material is lifted, etc.): Lifting is not usually required. Maximum consecutive time (minutes) during the normal workday for each activity: Sit: 408 Twist: 0 Stand: 24 Crawl: 0 Walk: 24 Kneel:0 Lift: 9 Drive: 0 Squat: 8 Climb: 0 Bend: 8 Reach above shoulders: 4
Repetitive use of hands (Frequency indicated):
Simple grasp up to 10 lbs.
Normal weight: 5- 10lbs frequent
Pushing &pulling Normal weight
Fine Manipulation: Terminal entry, calculator.
Repetitive use of foot or feet in operating machine control: None
Environmental Factors &Special Hazards Environmental Factors (Time Spent):
Inside hours: 40
Outside hours : 0
Temperature: Normal Range
Lighting: Average
Noise levels: Average
Humidity: Normal Range
Atmosphere: Dust &Poor Ventilation
Special Hazards: Protective Clothing Required: None