Medical Denial QA / QC

We are seeking a meticulous Medical Denial Quality Assurance (QA) / Quality Control (QC) specialist. The ideal candidate will possess strong expertise in denial management and medical billing processes, playing a critical role in reviewing and improving the accuracy of denial appeals and resolutions. This position is vital for optimizing revenue cycles and ensuring high-quality claim submissions.

Key Responsibilities

• Perform QA/QC reviews of denied medical claims to identify root causes and coding/billing errors.
• Analyze denial trends and patterns to provide actionable insights for process improvements.
• Verify the accuracy of information used in appealing denied claims, including coding, documentation, and payer-specific guidelines.
• Collaborate with AR (Accounts Receivable) teams and coders to implement corrective actions and prevent future denials.
• Develop and deliver training sessions to enhance team knowledge on denial prevention and effective appeal strategies.
• Maintain comprehensive records of audit findings, corrective actions, and their impact on denial rates.
• Ensure adherence to industry regulations and compliance standards related to medical billing and denials.

Qualifications

• Certification: Relevant coding or billing certification is preferred.
• Experience: Demonstrated experience in medical billing, AR follow-up, and denial management.

Skills

• Strong analytical and problem-solving skills for complex denial scenarios.
• In-depth knowledge of medical billing cycles, claim submission processes, and payer guidelines.
• Excellent communication skills, both written and verbal, for reporting and collaboration.
• Proficiency in medical billing software and relevant office applications.
• Ability to work meticulously and identify subtle discrepancies in documentation.