Healthcare Claims Denials Representative

Job ID
Employment Type
Hours Per Week


This position is responsible for Billing, Re-Billing, Post-payment and Account follow-up and/or grievance preparation of assigned Client Hospital Accounts Receivables, specific to the Out of State Medicaid claims. Working at a centralized location, responsibilities may include account maintenance of specialized or multiple payers including state and federal government programs, managed care, commercial and other insurance groups.  The Patient Account Specialist may serve as a liaison to clinical auditors, other team members, hospital staff, government agencies and health plans to facilitate the appropriate and prompt payment of claims. This individual must demonstrate a commitment to the organization’s strategic plans, short and long term goals and mission, vision and values by representing the company in a caring and professional manner.



  • Reviews and/or scrubs final billed initial claims for accuracy and completeness before submitting for payment
  • Obtains necessary patient records required as attachments to claims
  • Calculates Tier, Outlier, DRG and/or other Fee Schedule based reimbursement
  • Submits electronic and/or hardcopy claims with any attachments as per the contract timely filing criteria
  • Documents all account activity in the hospital system notes and the database


  • Within appropriate time frames, contacts the health plan by phone or website to determine status of claim
  • Documents all follow-up actions in the hospital account notes and database and sets up account for additional review based on client expectations for follow-up of unresolved accounts


  • Researches all account information on paid or partially paid claims and analyzes the status of the payment related to the expected payment calculation and itemization provided by the remittance advice
  • Determines if payment is appropriate according to contract specifications
  • Analyzes any denied, disallowed or non-covered claims and determines if non-payment is based on medical or technical reasons
  • Resolves any technical issues when warranted with health plans via phone or website
  • Prepares requests for account balance adjustments in accordance with client specific procedures
  • Prepares claims for clinical audit processing in the case of authorization, coding, level of care and/or length of stay denials
  • Processes overpayment transactions in accordance with client specific procedures
  • Follows guidelines for prioritization, timely filing deadlines, hospital and database documentation


  • Seeking prior experience with Out of State Medicaid claims
  • Knowledge and skills typically acquired through receipt of a diploma
  • Requires a minimum  of five years of related job experience
  • Experience in the health care field or with a health care services related business
  • Working knowledge of computer programs and technical applications
  • Excellent verbal and written communication skills are essential
  • Strong organizational and coordination abilities are required

About nThrive

nThrive is the leader in providing end-to-end revenue cycle services, technology and education solutions. Previously known as MedAssets, Precyse, Equation and Adreima, each formerly a leader in its own right, we’ve combined our talents and capabilities into a single enterprise. At nThrive, we are people who are passionate about empowering health care for every one in every community. We work together to transform financial and operational performance, enabling health care organizations to thrive.
nThrive is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, age, veteran status, disability, national origin, sex, sexual orientation, religion, gender identity or any other federal, state or local protected class.


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