Denial Reconciliation Specialist in Tustin, California at FAMILIES TOGETHER OF ORANGE COUNTY

Job Title: Denial Reconciliation Specialist

Salary: $28-$30 per hour (DOE)

Location: Tustin, CA

Openings: 1 FT

Position Purpose: The Denial Reconciliation Specialist is responsible for researching, correcting, appealing, reconciling, and resolving denied and rejected healthcare claims through final disposition. This position works closely with Revenue Cycle leadership and operational teams to identify the root causes of denials, recover outstanding reimbursement, reduce preventable denials, and improve overall revenue cycle performance.

The ideal candidate will have experience in an FQHC environment, strong knowledge of IPA and managed care reimbursement, and experience working with Medi-Cal, Medicare, Medicare Advantage, and commercial health plans. Experience with eClinicalWorks (eCW), Waystar, and FrontRunner is strongly preferred.

Core Duties and responsibilities, include but are not limited to:

1. Review and resolve denied and rejected claims in a timely manner.
2. Research denial reasons using eCW, Waystar, FrontRunner, payer portals, ERAs/EOBs, and other available resources.
3. Correct and resubmit claims and verify successful payer acceptance.
4. Prepare and submit reconsiderations & appeals with required supporting documentation.
5. Follow denied claims through final payment, adjustment, or appropriate resolution.
6. Monitor denial aging, timely filing limits, and payer appeal deadlines.
7. Research eligibility, authorization, coding, modifier, medical necessity, credentialing, NPI/TIN, duplicate claim, non-covered service, and payer-related denials.
8. Identify payer responsibility suck as health plan, IPA, patient, or other payer.
9. Research zero-pay claims, partial payments, recoupments, and payment discrepancies.
10. Identify recurring denial trends and perform root-cause analysis.
11. Escalate systemic issues to Revenue Cycle leadership and appropriate departments.
12. Work collaboratively with registration, front desk, authorization, coding, billing, credentialing, and clinical teams to prevent recurring denials.
13. Maintain accurate account documentation and follow-up activity.
14. Assist with weekly and monthly denial reporting, including denial dollars, aging, trends, appeals, recovered revenue, and preventable denials.

This job description in no way states or implies that these are the only duties to be performed by the employee. He or she will be required to follow any other instructions and to perform other duties, within scope, as assigned by his or her supervisor.

Education, Qualifications, and Experience:

• High school diploma or equivalent required.
• Minimum 3 years of medical billing, A/R, denial management, or healthcare revenue cycle experience.
• Demonstrated experience researching and resolving healthcare claim denials.
• Knowledge of EOBs, ERAs, CARC/RARC codes, claim status responses, and payer correspondence.
• Working knowledge of CPT, HCPCS, ICD-10-CM, modifiers, and general medical billing requirements.
• Knowledge of eligibility, authorizations, referrals, coordination of benefits, corrected claims, appeals, payment posting, adjustments, and A/R follow-up.
• Experience using payer portals and clearinghouse systems.
• Strong analytical, reconciliation, organizational, and problem solving skills.
• Able to manage high-volume accounts while meeting timely filing and appeal deadlines.
• Working knowledge of Microsoft Excel

Work Schedule:

• FTOC is an in-person organization first, and foremost. Employees are expected to be on-site for their scheduled shifts.
• Hours of operation are Monday to Friday 8 a.m. to 8 p.m., however, employee schedules vary, depending on organizational, staffing, community, and patient needs. As such, FTOC may need to modify work schedules to meet such needs.
• Holidays and weekends may be required depending on an employee’s department due to organizational, staffing, community, and patient needs as FTOC continues to grow and expand work days and hours.
• Overtime may also occur due to organizational, staffing, community, and patient needs.

Preferred Qualifications:

• Knowledge of FQHC PPS and managed care reimbursement.
• eClinicalWorks (eCW) experience strongly preferred.
• Waystar & FrontRunner experience strongly preferred.
• Experience working with IPAs, managed care organizations, and health plans.
• Understanding of Medi-Cal, MediCare, and Medicare Advantage program.
• Experience with denial root-cause analysis and prevention.
• Experience preparing payer reconsiderations and appeals.
• CPC, CPB, CRCR, or other billing/revenue cycle certification is a plus

Families Together of Orange County (FTOC) is proud to be an equal opportunity employer. FTOC does not discriminate based on race, color, creed, sex, sexual orientation, gender identity or expression, age, religion, national origin, disability, ancestry, marital status, veteran status, medical condition, or any protected category prohibited by local, state or federal laws.