**Become a part of our caring community and help us put health first**

The **Denials Management Specialist** is responsible to respond to, monitor and analyze all governmental requests, including but not limited to ADR’s, CERTS, RAC’s, ZPIC’s, SMRC’s, and all other revenue-driven denials and requests. Guides and coordinates with the branch staff in developing responses. Identifies the need for changes in policies, procedures, documentation strategies, and protocols based on regulatory requirements and makes recommendations as indicated.

**Essential Functions:**

+ Responsible for responding to, managing and monitoring all payer requests for additional documentation (ADR), appeals and denials. Works with branch staff to gather required information and ensure timely response to payer requests for additional documentation.

+ Monitors denials, collaborates with branch and billing staff to determine appropriate response, manages appeals process.

+ Monitors and responds to all requests related to revenue recovery including but not limited to Government and private payer requests.

+ Collaborates with branch and billing department staff to develop appropriate and timely responses.

+ Responsible for constructing response to denials and appeals, utilizing any federal guidelines or local coverage determination guidelines that are applicable to the record and response.

+ Monitors the development, interpretation and implementation of federal and governmental regulations. Coordinates the dissemination of information.

+ Provides trended reports for operations and clinical management in order to improve performance, collaborates with and acts as a resource for division and field support staff in identifying areas in need of attention/improvement.

+ Identifies the need for new and revised policies and training based on trends, changes in regulations, operations or clinical programs.

+ Participates in project team activities, and serves as a backup to divisional regulatory staff on issues of regulations, coverage, compliance and documentation.

+ Reviews records and operations as requested regarding compliance with policy and payer requirements.

+ Responsible for assigned tasks inside Waystar: entering, tracking, uploading records, etc.

+ Participates in and provides training as assigned.

+ Performs other related duties as assigned or requested.

**Use your skills to make an impact**

**Required Experience/Skills:**

+ Registered Nurse or Physical Therapist.

+ Current state license as a Registered Nurse or Physical Therapist.

+ 5 years of professional experience in Home Care, 2 years of which are in an administrative, supervisory, quality assurance or teaching position in/or related to a Medicare certified home health agency.

+ A thorough knowledge of federal regulations and Medicare requirements is required along with analytical skills to interpret and apply regulatory requirements.

+ Extensive knowledge of home care operations, compliance requirements and legal issues in home care.

+ Extensive experience in working with Payer requirements, both traditional Medicare and Medicare Advantage plans, ADR requests, Denials, Appeals, TPE, RCD, RAC, ZPIC, CERT, etc. responses are preferred.

+ Excellent written and verbal communications skills.

+ Must be able to multi-task and work well under pressure.

+ Must be able to learn Homecare Homebase and the Waystar system quickly and extensively.

+ Must be proactive, responsive and resourceful.

+ Highly flexible and motivated with an ability to work independently as well as in a team setting.

+ Must consistently demonstrate the highest level of professionalism and discretion.

+ Ability to work a flexible schedule and extended hours on occasion in order to meet deadlines and/or work on special projects.

+ Requires working under some stress conditions to meet deadlines and agency needs.

+ Must read, write and speak fluent English.

**To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:**

+ At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.

+ Satellite, cellular and microwave connection can be used only if approved by leadership.

+ Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.

+ Home or Hybrid Home/Office employees will be provided with telephone equipment appropriate to meet the business requirements for their position/job.

+ Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

**CenterWell Home Health offers a variety of benefits to promote the best health and well-being of our employees and their families. Our competitive and flexible benefits surround you with support the same way you do for our patients and members, including:**

+ Health benefits effective day 1

+ Paid time off, holidays, and jury duty pay

+ Recognition pay

+ 401(k) retirement savings plan with employer match

+ Tuition assistance

+ Scholarships for eligible dependents

+ Caregiver leave

+ Employee charity matching program

+ Network Resource Groups (NRGs)

+ Career development opportunities

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

**Scheduled Weekly Hours**

40

**Pay Range**

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$65,000 - $88,600 per year

**Description of Benefits**

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

Application Deadline: 07-13-2025

**About us**

About CenterWell Home Health: CenterWell Home Health specializes in personalized, comprehensive home care for patients managing a chronic condition or recovering from injury, illness, surgery or hospitalization. Our care teams include nurses, physical therapists, occupational therapists, speech-language pathologists, home health aides, and medical social workers – all working together to help patients rehabilitate, recover and regain their independence so they can live healthier and happier lives.

About CenterWell, a Humana company: CenterWell creates experiences that put patients at the center. As the nation’s largest provider of senior-focused primary care, one of the largest providers of home health services, and fourth largest pharmacy benefit manager, CenterWell is focused on whole-person health by addressing the physical, emotional and social wellness of our patients. As part of Humana Inc. (NYSE: HUM), CenterWell offers stability, industry-leading benefits, and opportunities to grow yourself and your career. We proudly employ more than 30,000 clinicians who are committed to putting health first – for our teammates, patients, communities and company. By providing flexible scheduling options, clinical certifications, leadership development programs and career coaching, we allow employees to invest in their personal and professional well-being, all from day one.

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**Equal Opportunity Employer**

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.

Centerwell, a wholly owned subsidiary of Humana, complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our full accessibility rights information and language options https://www.partnersinprimarycare.com/accessibility-resources