The Healthcare Claims Denial Management Specialist is responsible for identifying, analyzing, and resolving denied, rejected, and underpaid medical insurance claims to ensure accurate and timely reimbursement. This role works closely with insurance payers, internal billing teams, coding teams, and healthcare providers to investigate claim issues, submit corrections and appeals, and improve overall revenue cycle performance.
The ideal candidate will have strong knowledge of healthcare billing processes, payer requirements, medical coding guidelines, and denial resolution strategies. This position requires excellent analytical skills, attention to detail, and the ability to manage multiple cases while maintaining compliance with regulatory and payer-specific requirements.
Essential Duties and ResponsibilitiesDenial Review & Resolution
- Review and analyze denied, rejected, and underpaid medical claims to identify root causes and resolution strategies.
- Research claim discrepancies, coding issues, documentation gaps, and payer requirements.
- Correct claim errors, update coding or documentation as needed, and resubmit claims within required payer deadlines.
- Follow up with insurance companies to resolve outstanding denials and secure appropriate reimbursement.
Payer Communication & Documentation
- Communicate directly with insurance representatives to verify claim status, obtain clarification, and resolve payment discrepancies.
- Maintain detailed documentation of claim activity, payer correspondence, actions taken, and final resolutions within billing and practice management systems.
- Partner with internal billing and clinical teams to gather necessary documentation and resolve claim issues.
Root Cause Analysis & Denial Prevention
- Identify denial trends and recurring issues across payers, service lines, coding categories, and workflows.
- Collaborate with coding, billing, and operational teams to implement process improvements and reduce future denials.
- Provide feedback and recommendations related to documentation improvements, coding accuracy, and payer requirements.
Appeals Management
- Prepare and submit formal appeals with supporting documentation, medical records, coding references, and payer policy guidelines.
- Monitor appeal deadlines and track outcomes to ensure timely resolution.
- Analyze appeal results and identify opportunities to improve reimbursement outcomes.
Compliance & Quality Assurance
- Ensure all claim submissions, corrections, and appeals comply with federal, state, and payer-specific regulations.
- Maintain knowledge of payer policies, reimbursement guidelines, and healthcare coding standards, including CPT, HCPCS, and ICD-10.
- Follow industry best practices related to revenue cycle management and claims resolution.
Reporting & Performance Tracking
- Generate denial reports and analyze trends to provide insights to leadership.
- Track key performance indicators (KPIs), including denial rates, appeal success rates, reimbursement outcomes, and accounts receivable performance.
- Maintain accurate records and reporting related to denial management activities.
Required Qualifications
- 2–4 years of experience in medical billing, claims processing, denial management, or revenue cycle operations within a healthcare environment.
- Strong understanding of:
- Revenue cycle management processes
- CPT, HCPCS, and ICD-10 coding guidelines
- Commercial insurance, Medicare, and Medicaid payer requirements
- Medical terminology and healthcare reimbursement practices
- Experience working with EMR/EHR systems, clearinghouses, and medical billing software.
- Strong analytical skills with the ability to identify trends, investigate issues, and develop solutions.
- Excellent written and verbal communication skills with the ability to interact effectively with payers, providers, and internal teams.
- Strong organizational skills with the ability to manage multiple priorities, meet deadlines, and maintain accurate documentation.
Preferred Qualifications
- CPC, CPB, or other AAPC/AHIMA healthcare certification.
- Experience working in a high-volume claims or revenue cycle environment.
- Experience handling payer appeals, audits, or complex claim disputes.
- Knowledge of anesthesia billing, facility billing, or specialty practice management preferred.
Pay: $27.00 - $29.00 per hour
Work Location: In person
