HealthDrive is seeking a full-time Medical and Dental Claims Denial Resolution Specialist to join our team! The Medical and Dental Claims Denial Resolution Specialist is responsible for daily review and resolution of insurance claim denials and/or unpaid/incorrectly paid claims with the primary goal to increase cash collections and minimize bad debt write-offs.

This individual must have extensive experience working with claim denial resolution for all insurance plan types; Medicare Part B, Medicare Advantage, Medicaid, Medicaid MCO, Private Insurance and BCBS, including but not limited to:
Aetna Medicare, AARP Medicare, BCBS TX, Cigna HealthSpring, Dentaquest, Envolve Vision, EyeMed, Humana Dental, Humana Medicare, Kelsey Care Advantage, March Vision, Medicare TX, Medicaid -TMHP, Molina HealthCare of Texas, Molina Medicare/Medicaid (MMP Plan), Provider Partners Health Plan of TX, ProCare Advantage Medicare, Scott and White Health Plan, Spectera EyeCare, Superior Health Star, Texas Independence Health Plan, United HealthCare (Medicare Advantage, Dual and Medicaid plans), WellCare Health and Wellpoint MMP plans. The hourly pay range for this position is $22.00 - $27.00 per hour.

We are conveniently located off Route 9 in Framingham, MA, close to routes 90 and 495 in a spacious modern office with a workout center available right in the building! Candidates with significant experience in claim denial resolutions for the Texas insurance plans listed above may be considered for a full-time remote position in Texas.

What's in it for you: PPO Medical, Dental, and Vision Insurance, 401(k) + Company match, Paid Time Off, hybrid schedule opportunity, Verizon Wireless, Dell, and other employee discounts, profit sharing, and employee referral bonuses.

HealthDrive delivers on-site dentistry, optometry, podiatry, audiology, behavioral health, and primary care services to residents in long-term care, skilled nursing, and assisted living facilities. Each specialty offered by HealthDrive is one that directly impacts the quality of daily life for the deserving residents we serve. HealthDrive connects patients in need of vital healthcare to doctors committed to dignity and excellence.

• Identify, investigate, and follow-up with insurance plans daily to expedite resolution of denied, incorrectly paid, or unpaid claims.
• Submit corrected claims and appeals online to obtain payment within the insurance plan timely filing and appeal limits.
• Obtain and verify new/corrected insurance information using clearinghouse or insurance websites prior to rebilling claims to new/updated insurances.
• Document and communicate ongoing denial or incorrect payment issues for a specific insurance plan which require assistance from manager and/or director to help resolve.
• Become the expert on the billing and claim requirements for assigned insurance plans.
• Utilize insurance plan website(s) to check eligibility, claim status, submit online appeals, or provide Explanation of Benefits (EOB’s) / Explanation of Payments (EOP’s) required for processing secondary/tertiary claims.
• Review and resolve overpayments, submit requests for insurance to retract their payment, and as needed request refund through automated process in billing system.
• Identify and communicate payment posting issues to cash application team.
• Meet or exceed daily productivity objectives for all assigned duties.
• Respond to email inquiries or teams chat messages regarding questions/issues with your assigned AR plans within 24 hours.
• Work professionally and cooperatively with facilities, responsible parties, insurance carriers, and all internal and external customers.
• Assist with development of training materials/cheat sheets for assigned insurance plans and actively participate in training of other employees on as needed basis.
• Other duties and tasks assigned or necessary to meet business needs/objectives.

• Prefer minimum of 5 years; experience in professional physician multispecialty group managing medical and dental claims denial resolution.
• Extensive knowledge of Third-Party billing practices and regulations for insurances in Texas (Medicare Part B, Medicare Advantage, Medicare Supplemental, BCBS, Private Insurance, Medicaid, and Medicaid Managed Care plans).
• Knowledgeable of the claim adjustment (CARC) and the remark reason codes (RARC) from Electronic Remittance Advices (ERA/835 files) and from paper Explanation of Benefits (EOB’s) / Explanation of Payments (EOP’s), CPT, and ICD10 codes.
• Highly organized, with excellent attention to detail and exceptional/persistent follow-up, problem-solving and analytical skills.
• Must have strong ability to self-direct and work independently in a high-volume, deadline-driven role.
• Demonstrates proficiency in computer skills including Microsoft Office Applications (Excel, Outlook, Word and Teams), medical billing Software, insurance plan websites, and provider manuals.
• Excellent interpersonal and communication skills with professional demeanor and positive attitude who readily adapts to change and effectively and appropriately communicates both verbally and in writing.
• Collaborator with ability to establish priorities, effectively multitask to meet objectives and deadlines.
• Strong time management and organizational skills; demonstrated ability to independently prioritize.
• Knowledge of HIPAA regulations and patient privacy rules.