Eligibility Denial Specialist III

WHY UT SOUTHWESTERN?
With over 75 years of excellence in Dallas-Fort Worth, Texas, UT Southwestern is committed to excellence, innovation, teamwork, and compassion. As a world-renowned medical and research center, we strive to provide the best possible care, resources, and benefits for our valued employees. Ranked as the number 1 hospital in Dallas-Fort Worth according to U.S. News & World Report, we invest in you with opportunities for career growth and development to align with your future goals. Our highly competitive benefits package offers healthcare, PTO and paid holidays, on-site childcare, wage, merit increases and so much more. We invite you to be a part of the UT Southwestern team where you'll discover a culture of teamwork, professionalism, and a rewarding career!

JOB SUMMARY

• The Eligibility Denial Specialist III is responsible for researching any denied claim for both professional and hospital billing based on eligibility to ensure correct payers are billed timely on submitted insurance claims.
• The role will be responsible for managing and resolving outstanding correspondence related to refund requests from insurance carriers.
• This role involves reviewing refund requests, determining their validity, disputing questionable refunds, and communicating directly with insurance companies to resolve issues.
• The individual will also be tasked with completing dispute letters, conducting follow-ups, and handling appeals to ensure proper resolution of refund issues.
• Experience in insurance billing, registration, and a keen understanding of the refund process will be key to successfully managing these tasks.
• This position requires strong attention to detail, the ability to effectively communicate with insurance carriers, and a solid understanding of billing and refund processes within the healthcare industry.
• Serve as a team lead, handle complex and escalated refund matters, train and mentor staff, lead workflow activities, and assist the supervisor with operational needs and team support.

Shift - 8 hour days, Monday through Friday. Flex starts between 0600-0900

Work from home (WFH) - The candidate will work from home and must live within the Greater Dallas-Fort Worth (DFW) area

Our Culture:

Our teams' culture is Love Based, which thrives on mutual respect, empathy, and support, fostering an environment where every member feels valued and empowered. It prioritizes open communication, collaboration, and understanding, creating a cohesive and inclusive community where individuals can flourish personally and professionally. Love Based cultivates a culture where kindness, compassion, and appreciation are foundational principles, leading to greater creativity, productivity, and fulfillment for all team members.

Hard Skills

• Experience with reviewing and resolving refund request correspondence from various insurance carriers.
• Knowledge and experience with submitting dispute letters to insurance carriers and following up to track the status of refund disputes.
• Knowledge and experience in processing and issuing refunds in compliance with company policies, along with a strong understanding of insurance billing practices and regulations to resolve billing discrepancies.
• Ability to communicate effectively with insurance carriers via phone or written communication to resolve refund issues.
• Experience with online payer portals to manage refund requests and disputes.
• Knowledge of registration processes to resolve issues impacting patient or insurance account details related to refunds.
• Ability to multitask and prioritize tasks effectively while handling multiple refund disputes and requests.
• Advanced experience researching and resolving complex or escalated refund requests, disputes, and appeals.
• Experience monitoring work queues, correspondence inventory, aging, productivity, and workflow priorities.
• Experience training staff and explaining refund processes, payer requirements, dispute documentation, and resolution steps.
• Ability to analyze refund trends, identify root causes, and recommend process improvements.
• Ability to lead workflow activities and assist with quality review and operational follow-up.

Soft Skills

• Outlook experience
• Outlook Teams App experience
• Excel experience
• Medical Terminology
• Payer Portal experience
• Leadership and team coordination skills
• Ability to coach, train, and provide constructive guidance to team members
• Strong critical thinking, problem-solving, and decision-making skills
• Professional communication and collaboration skills
• Ability to remain organized, dependable, and adaptable while supporting multiple priorities

BENEFITS
UT Southwestern is proud to offer a competitive and comprehensive benefits package to eligible employees. Our benefits are designed to support your overall wellbeing, and include:

• PPO medical plan, available day one at no cost for full-time employee-only coverage
• 100% coverage for preventive healthcare-no copay
• Paid Time Off, available day one
• Retirement Programs through the Teacher Retirement System of Texas (TRS)
• Paid Parental Leave Benefit
• Wellness programs
• Tuition Reimbursement
• Public Service Loan Forgiveness (PSLF) Qualified Employer
• Learn more about these and other UTSW employee benefits!

EXPERIENCE AND EDUCATION

Required

• Education
  High School Diploma or equivalent
  

• Experience
  6 years medical billing, claims processing, and/or insurance eligibility experience.
  May consider medical billing certifications or graduate degrees in lieu of experience.
  

JOB DUTIES

• Review, research and resolve denied insurance claims for both professional and hospital billing based on eligibility through the billing system, including Medicaid, Medicare, Worker's Compensation, Mental Health payers and third-party payers.
• Interpret Explanation of Benefits from insurance companies on denied claims.
• Contact payers via website, phone and/or correspondence regarding claims denied for eligibility.
• Contact patients and assist with Coordination of Benefits or other coverage denials.
• Works in all professional billing service areas.
• Updates registration and demographic information in all hospital billing service areas.
• Resolves eligibility denials in all clearinghouse and payer rejection WQ's.
• Review and resolve any Visit Filing order changes and work advanced Visit Filing Order WQ's.
• Function as a liaison between clinical departments and third-party payers.
• Completes special projects as requested.
• Identifies problems and inconsistencies by using management reports; summarizes findings and makes recommendations to resolve billing issues in an effort to maximize collections.
• Duties performed may include one or more of the following core functions: (a) Directly interacting with or caring for patients; (b) Directly interacting with or caring for human-subjects research participants; (c) Regularly maintaining, modifying, releasing or similarly affecting patient records (including patient financial records); or (d) Regularly maintaining, modifying, releasing or similarly affecting human-subjects research records.
• Performs other duties as assigned.

SECURITY AND EEO STATEMENT

Security
This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information.

EEO
UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. As an equal opportunity employer, UT Southwestern prohibits unlawful discrimination, including discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status.