USRN Quality Analyst ( QA) | Denials and Appeals | WFH after training
We currently looking for USRN Quality Analyst to be part of our PIONEER USRN TEAM!
This role focuses on the comprehensive analysis, management, and resolution of denials and appeals related to claims and services, ensuring compliance with insurance policies, healthcare regulations, and industry best practices.
Key Responsibilities:
Denials and Appeals Management:
- Analyze and review denied claims and appeal submissions, ensuring accuracy and timely resolution.
- Assess medical necessity, coding, and documentation to identify the root causes of claim denials.
- Collaborate with healthcare providers, payers, and internal teams to develop and submit detailed, evidence-based appeals.
Quality Assurance:
- Perform comprehensive audits and quality checks on denied claims and appeal resolutions.
- Review claim data, policies, and denial trends to identify patterns or opportunities for process improvements.
- Ensure all appeals are processed according to established guidelines and in compliance with healthcare regulations (e.g., CMS, HIPAA).
Collaboration and Reporting:
- Provide feedback to clinical teams on documentation or coding issues contributing to denials.
- Create and maintain denial and appeals trend reports to share with leadership for decision-making.
- Work closely with claims processors, coders, and other healthcare professionals to ensure accurate and efficient claims management.