Denial Management Specialist

Candidates must reside in Lahore or Islamabad to be eligible for this remote Denial Management Specialist position. In this role, you will focus on denial prevention, claim review, coding accuracy, and appeal processing. Your responsibilities will include investigating denied claims, identifying coding and documentation issues, correcting and resubmitting claims, and collaborating with providers, insurance representatives, and internal billing teams to ensure timely reimbursement. Additionally, you will monitor payer and regulatory updates, analyze denial trends, and support provider and staff education as needed. The work schedule is Monday through Friday, with hours based on client requirements across various U.S. time zones (PST/MST/EST/CST).

Key Responsibilities
- Follow up on denied claims from commercial and contracted payers, particularly those related to coding errors.
- Assign and sequence ICD-10-CM and CPT-4 codes, reviewing physician documentation for coding accuracy.
- Correct coding issues in compliance with Medicare and AMA coding guidelines.
- Review and analyze medical records to ensure accurate ICD and CPT code selection.
- Serve as a coding subject matter expert within the denial management function.
- Thoroughly investigate denied claims and determine appropriate resubmission strategies.
- Coordinate with providers, insurance representatives, collection specialists, and charge posters to resolve claim issues.
- Validate and follow up on denied claims, including initial assessment of denials received through EDI.
- Identify coding trends contributing to increased denial volumes and escalate findings to management.
- Resolve routine coding issues and identify opportunities for additional staff and provider training.
- Stay informed about changes in payer requirements and applicable state and federal regulations.
- Support special projects such as provider and staff training and education.
- Maintain strict HIPAA compliance and confidentiality of patient information.
- Participate in Quality Assurance/Quality Improvement (QA/QI) activities and organizational performance improvement initiatives.
- Utilize Electronic Health Record (EHR) and Practice Management systems as required.

Required Qualifications
- High School Diploma or GED.
- CPC, CPCH, and/or CCS-P certification.
- Minimum of 2 years of billing and accounts receivable experience in a physician practice.
- At least 2 years of experience working in a Federally Qualified Health Center (FQHC) environment.
- Minimum 3 years of physician coding experience in a multi-specialty setting.
- Strong working knowledge of ICD-10-CM and CPT-4 coding.
- Familiarity with coding rules and third-party payer requirements.
- Ability to maintain annual coding certification requirements.
- Strong analytical skills within a medical billing environment.
- Proficiency in Microsoft Excel and Office products.
- Excellent communication skills when interacting with providers and management.
- Ability to work effectively under pressure.
- Solid understanding of denial management and claim follow-up processes.

Preferred Qualifications and Benefits
- Experience using 3M Encoder and/or Encoder Pro, Electronic Health Record (EHR) systems, Practice Management systems, and EDI/claims processing systems.
- Opportunity to work with leading North American healthcare organizations without relocating.
- Access to a growing global healthcare talent community and long-term career growth.
- Exposure to U.S. healthcare billing, coding, and revenue cycle operations.
- Participation in organizational performance improvement initiatives and ongoing professional development.

Compliance and Quality
- Maintain compliance with HIPAA regulations and protect confidential patient information.
- Ensure adherence to applicable local, state, and federal regulations.
- Engage actively in Quality Assurance and Quality Improvement activities.

Hiring Process
Candidates will undergo a multi-step hiring process including application review, skills assessment, client interviews, and final selection. Successful applicants will join the Edge Global Talent Network, connecting them with healthcare opportunities across North America.

Edge is an equal opportunity employer committed to diversity and inclusion. All qualified applicants will be considered without regard to race, gender, religion, sexual orientation, disability, or other legally protected status.