Performs day-to-day payment resolution activities within the Hospital and/or Medical Group partner revenue operations. Scope of responsibility includes all post-billed denials (inclusive of clinical denials). Serves as part of the Denials Resolution team responsible for ensuring payments are received on denied accounts, determining root causes for discrepancies, minimizing inappropriate payment delays and variances from expected reimbursement, and resolving or escalating issues.

Duties and Responsibilities

• Knows, understands, incorporates, and demonstrates the Healthrise Core Values.
• Performs daily activities as part of the payment resolution team that receives, analyzes, and appeals denials. Reviews, researches, and resolves payment delays and/or variances resulting from rejected and/or denied claims, overpayments, or underpayments.
• Processes payments as appropriate in accordance with contracts and policies to ensure timely and accurate liability resolution.
• Resolves claims, conducts formal account reviews, identifies lost charge recovery, and analyzes/documents delays and payment variances.
• Identifies routine issues and resolves or escalates them as appropriate.
• Maintains knowledge of state and federal laws as they relate to contracts and the appeals process.
• Investigates and addresses overpayment and underpayment accounts with the goal of optimizing reimbursement.
• Coordinates follow-up with clinical departments to provide support for appeals.
• Collaborates with Patient Access and other stakeholders to resolve account authorization issues.
• Applies knowledge of payer rules, contracts, schedules, and other data sources to resolve payment variances.
• Proactively follows up on delays and variances with patients, commercial, Medicare, and Medi-Cal payers to ensure prompt reimbursement, refiles accurate claims, and documents findings.
• Contacts insurance carriers and patients as necessary to resolve outstanding balances.
• Monitors timely filing limits specific to California payers and ensures all claims are submitted within state and payer deadlines.
• Researches payer trends and provides feedback to improve billing accuracy and efficiency.
• Tracks and reports denial types and root causes, recommending process improvements.
• Analyzes, categorizes, and resolves claim denials from commercial, government, and managed care payers.
• Identifies root causes of denials (coding errors, eligibility issues, missing documentation, etc.) and works with clinical and coding teams for resolution.
• Files appeals and reconsiderations according to California-specific appeal timelines.
• Requests write-offs, transfers, allowances, and reversals as needed.
• Recommends accounts for transfer to collection vendors based on complexity and status.
• Documents all actions in the patient accounting system.
• Responds to patient and payer inquiries or refers them as needed.
• Communicates with physicians, office staff, and hospital departments to gather and verify necessary information.
• Prepares and submits reports documenting trends, outcomes, and claim activity.
• Cross-trains in various functions to enhance service delivery.
• Interprets data, draws conclusions, and reviews findings with supervisor.
• Continuously learns all aspects of the Denials Resolution Specialist role.
• Performs other duties as assigned.
• Maintains a working knowledge of applicable Federal, State, and local laws/regulations. 

• High school diploma or Associate degree in Accounting, Business Administration, or related field, with a minimum of two (2-3) years of experience in revenue cycle medical billing, insurance follow-up, and denial management functions in a hospital, clinic, insurance company, managed care organization, or similar healthcare financial service setting; or an equivalent combination of education and experience. Experience in a complex, multi-site environment within California healthcare systems preferred.
• Excellent written and verbal communication and organizational skills.
• Strong interpersonal and customer service skills.
• Attention to detail, accuracy, and time management.
• Basic proficiency in Microsoft Office (Outlook, Word, PowerPoint, Excel).
• Completion of regulatory/mandatory certifications preferred.
• Comfortable working in a collaborative, shared leadership environment.
• Previous experience with Global Partner vendors preferred.
• Experience using Epic.
• Strong understanding of California-specific payers (Medi-Cal, Blue Shield of CA, Kaiser, CalOptima, IEHP, Partnership HealthPlan, Division of Financial Responsibility, etc.).
• Familiarity with CPT, ICD-10, and HCPCS coding.
• Strong organizational, communication, and problem-solving skills.
• Ability to work independently, meet deadlines, and maintain high attention to detail.

Preferred

• Certification: Certified Professional Biller (CPB), Certified Medical Reimbursement Specialist (CMRS), or equivalent.
• Experience with California Medicaid (Medi-Cal), Share of Cost, and managed care environments.
• Bilingual (English/Spanish) preferred.