Authorization Denials Representative

Company Overview

Shriners Children’s is an organization that respects, supports, and values each other. Named as the 2025 best mid-sized employer by Forbes, we are engaged in providing excellence in patient care, embracing multi-disciplinary education, and research with global impact. We foster a learning environment that values evidenced based practice, experience, innovation, and critical thinking. Our compassion, integrity, accountability, and resilience define us as leaders in pediatric specialty care for our children and their families.

All employees are eligible for medical coverage on their first day! In addition, upon hire all employees are eligible for a 403(b) and Roth 403 (b) Retirement Saving Plan with matching contributions of up to 6% after one year of service. Employees in a FT or PT status (40+ hours per pay period) will also be eligible for paid time off, life insurance, short term and long-term disability and the Flexible Spending Account (FSA) plans and a Health Savings Account (HSA) if a High Deductible Health Plan (HDHP) is elected. Additional benefits available to FT and PT employees include tuition reimbursement, home & auto, hospitalization, critical illness, pet insurance and much more! Coverage is available to employees and their qualified dependents in accordance with the plans. Benefits may vary based on state law.

Job Overview

The Authorization Denials Representative is responsible for following up on payor responses to SHC submitted appeals. They will contact insurance carriers to ensure timely payment and collection of money due to the SHC organization after the appeals process has successfully taken place. The representative will verify that concurrent review medical records have been received by the payer and will communicate with Utilization Review if records are not on file.

Responsibilities

• Coordinates payer denial and appeal follow up activities to ensure appeals are on file and are being processed by the third-party payer, to include ensuring the payer has all documentation required to process the appeal.
• Maintains the healthcare tracking tool/application that stores/communicates all denial and review activity. This will include user access management, updates to software, and end-user training to support all follow up activities.
• Collects/analyzes report status, metrics and trends of activity by different reviews from the tool. Distributes reports on a routine basis to specific distribution groups.
• Organizes all data and activity in a retrievable way to ensure timely follow up on appeals to third party payors.
• Assists with the coordination of denial and review activities and materials for committee meetings, including analyses, reports, etc.
• Supports projects and initiatives of the Authorization Denials Management team. This may include coordinating meetings, conducting research for payer criteria, and preparing documents.
• Verifies concurrent review medical records have been received by the third-party payer and communicates with UR if additional submission is required.

This is not an all-inclusive list of this job’s responsibilities. The incumbent may be required to perform other related duties and participate in special projects as assigned.

Qualifications

Required:

• 1-3 years of healthcare revenue cycle experience
• Knowledge of Healthcare Revenue Cycle revenue management
• Knowledge of transaction sets including 837I, 837P, 835 and EOB responses
• Knowledge of insurance contract rates and terms
• Knowledge of registration and authorization processes
• Knowledge of government and managed care billing, coverage, authorization and payment rules
• High School Diploma/GED

Preferred:

• Epic EMR experience
• Knowledge of SQL or Crystal Reports
• Bachelor's degree