Appeals & Denials Specialist

Duties/Responsibilities

• Review and analyze denied, rejected, and underpaid claims to determine appropriate resolution strategies.
• Research payer policies, contracts, remittance advice, and supporting documentation to identify denial causes.
• Prepare, submit, and track first-level, second-level, and reconsideration appeals within payer-specific filing deadlines.
• Draft clear and effective appeal letters using supporting clinical, billing, and coding documentation.
• Collaborate with coding, billing, provider, and clinical teams to obtain required information for successful appeal outcomes.
• Monitor appeal status and follow up with insurance carriers to ensure timely resolution.
• Maintain detailed documentation of all appeal activity in practice management and claims systems.
• Identify denial trends and recurring issues and communicate findings to leadership.
• Afford recommendations to reduce future denials and improve clean claim rates.
• Ensure compliance with payer regulations, HIPAA requirements, and company policies.
• Meet productivity, quality, accuracy, and turnaround-time expectations.

Required Skills/Abilities

• Strong understanding of denial management concepts, including: Medical necessity denials, Authorization denials, Coding denials, Eligibility denials, Timely filing denials, Coordination of benefits denials.
• Excellent written communication skills with the ability to prepare professional appeal correspondence.
• Strong organizational, analytical, and problem-solving abilities.
• Proficiency with Microsoft Office, including Excel and Outlook.

Education and Experience

• High school diploma or GED required.
• Minimum 2 years of healthcare Revenue Cycle Management, medical billing, accounts receivable, denials, or appeals experience.
• Knowledge of commercial, Medicare, Medicaid, and Managed Care payer requirements.
• Experience working with EOBs, ERAs, payer portals, and claims adjudication processes.