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Denial Clerk – Coordinator

Summary

The denial coordinator is responsible for preparing and processing denial notifications for managed care members. Must have knowledge of healthcare, medical terminology and managed care.  Must be proficient in MS Office programs (i.e., Word, Excel). Good communication skills for speaking with health plans, provider’s offices and members. Needs to have the ability to multi-task and prioritize. The denial coordinator must be able to handle these responsibilities with confidentiality.


Duties and Responsibilities

  • Reviews authorizations as they come in.
  • Check all notes for medical necessity or benefit coverage
  • Check previous authorizations, claims and notes, back history etc.
  • Type the appropriate letter according to health plan and product line (Medi-Cal, Commercial, Medicare, Medi-Medi, Cal MediConnect and CCS) in English and threshold language if necessary.
  • Verify that the proper criteria are stated for the denial/modification using each health plan’s E.O.C. and/or Medi-Cal, CMS matrixes for benefit denials and denial matrix for medical necessity denials.
  • Enter in notes section that it was denied/modified and enter reason from the letter
  • Fax denial letter to requesting and/or requested physician and mail copy of letter in appropriate language to member.
  • Fax copy of denial letters in both languages, confirmation from physician’s office along with our medical review form, and notes to health plans.

Minimum Job Requirements:

  • High school graduate

Knowledge, Skills and Abilities Required:

  • One year medical office experience.
  • Completion of medical terminology class.
  • Denial process knowledge.
  • One year UM experience.

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Job title: Denial Clerk – Coordinator

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