Sr. Denials & Appeals Specialist
Baylor Genetics
Summary
The Sr. Denials & Appeals Specialist will manage complex insurance denials and oversee the appeals process to ensure accurate reimbursement and minimize revenue loss. This role involves analyzing denied claims, identifying trends, and developing strategies to prevent future denials. The Sr. Denials & Appeals Specialist will collaborate with departments including billing, coding, and customer service to resolve issues and optimize the revenue cycle process. This position will require strong knowledge of payer requirements, healthcare billing codes, and a deep understanding of claims management.
Job description
Key Responsibilities
- Oversee and manage the appeals process for denied claims, ensuring timely and accurate submission of appeal documentation according to payer guidelines. Handle complex or high-value denials, consulting with appropriate staff to resolve outstanding issues.
- Analyze denied claims to identify root causes, trends, and patterns. Work collaboratively with departments to implement corrective actions and prevent recurrence.
- Work closely with billing, coding, payer relations, and clinical teams to address issues related to denials. Provide guidance on proper coding, documentation, and billing practices.
- Ensure that all denials and appeals are handled in compliance with applicable regulations and guidelines (e.g., HIPAA), and maintain thorough and accurate documentation.
- Prepare and submit detailed and timely appeal letters and supporting documentation to payers, following specific payer requirements.
- Provide training and support to junior denials and appeals specialists on best practices, guidelines, and payer requirements. Foster a collaborative work environment.
- Track key performance indicators (KPIs) related to the denials and appeals process, including appeal success rates, denial trends, and resolution times. Report findings to senior management.
Qualifications
- College degree preferred or equivalent experience of 5 plus years
- 5 years' experience in medical billing; strong preference will be given to candidates with molecular laboratory billing experience. Medical billing experience may be substituted for a bachelor's degree.
- Understanding of patient protections under HIPAA and proper handling of protected health information (PHI).
- Working knowledge of health insurance and terminology.
- Excellent communication and people skills.
- Meticulous with strong analytical and problem-solving abilities.
Skills
- Strong knowledge of insurance guidelines, CPT/ICD-10 codes, and medical terminology.
- Excellent attention to detail and time management skills.
- Effective communication and problem-solving abilities.
- Proficiency in Microsoft Office Suite and healthcare software tools.
Requirements
- College degree preferred or equivalent experience of 5 plus years
- 5 years' experience in medical billing
- Molecular laboratory billing experience preferred
- Understanding of patient protections under HIPAA and proper handling of protected health information (PHI)
- Working knowledge of health insurance and terminology
- Excellent communication and people skills
- Meticulous with strong analytical and problem-solving abilities
- Strong knowledge of insurance guidelines, CPT/ICD-10 codes, and medical terminology
- Excellent attention to detail and time management skills
- Effective communication and problem-solving abilities
- Proficiency in Microsoft Office Suite and healthcare software tools
Company overview
Baylor Genetics is a leading diagnostic genomics company that pioneered the history of genetic testing and now serves as a premier precision diagnostics partner. Founded in 1978 and headquartered in Houston's Texas Medical Center, the company offers a comprehensive spectrum of clinically relevant genetic testing services including Whole Genome Sequencing, Whole Exome Sequencing, and targeted panels. Baylor Genetics combines advanced genomic technologies with genetic counseling support to help clinicians shorten diagnostic journeys for patients with rare diseases and complex genetic conditions. Their testing menu spans family planning, pregnancy, pediatrics, oncology, and specialized diagnostic areas, serving clients across all 50 U.S. states and 16 countries internationally. The company's mission focuses on providing rapid, comprehensive precision diagnostics to guide medical management and ensure no patient with a genetic disorder is left behind. Baylor Genetics operates as a clinical laboratory that translates complex genomic insights into actionable clinical information, supporting healthcare providers in making informed decisions for patient care across various medical specialties.