Job Summary:
The Appeals & Denials Specialist is responsible for the timely review, investigation, and resolution of denied or underpaid healthcare claims. This role works directly with payers, providers, and internal stakeholders to identify denial root causes, prepare and submit appeals, and maximize reimbursement opportunities. The ideal candidate has strong analytical skills, payer knowledge, and experience navigating complex denial and appeals processes within a healthcare revenue cycle environment.
Supervisory Responsibilities:
This position has no direct supervisory responsibilities.
Duties/Responsibilities:
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Review and analyze denied, rejected, and underpaid claims to determine appropriate resolution strategies.
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Research payer policies, contracts, remittance advice, and supporting documentation to identify denial causes.
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Prepare, submit, and track first-level, second-level, and reconsideration appeals within payer-specific filing deadlines.
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Draft clear and effective appeal letters using supporting clinical, billing, and coding documentation.
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Collaborate with coding, billing, provider, and clinical teams to obtain required information for successful appeal outcomes.
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Monitor appeal status and follow up with insurance carriers to ensure timely resolution.
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Maintain detailed documentation of all appeal activity in practice management and claims systems.
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Identify denial trends and recurring issues and communicate findings to leadership.
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Assist in developing recommendations to reduce future denials and improve clean claim rates.
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Ensure compliance with payer regulations, HIPAA requirements, and company policies.
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Meet productivity, quality, accuracy, and turnaround-time expectations.
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Performs other duties as assigned.
Required Skills/Abilities:
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Strong understanding of denial management concepts, including:
- Medical necessity denials
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Authorization denials
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Coding denials
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Eligibility denials
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Timely filing denials
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Coordination of benefits denials
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Excellent written communication skills with the ability to prepare professional appeal correspondence.
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Strong organizational, analytical, and problem-solving abilities.
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Proficiency with Microsoft Office, including Excel and Outlook.
Education and Experience:
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High school diploma or GED required
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Minimum 2 years of healthcare Revenue Cycle Management, medical billing, accounts receivable, denials, or appeals experience.
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Knowledge of commercial, Medicare, Medicaid, and Managed Care payer requirements.
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Experience working with EOBs, ERAs, payer portals, and claims adjudication processes.
Physical Requirements:
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Prolonged periods of sitting at a desk and working on a computer.
