Complex Revenue Recovery Specialist

Core Competencies

• Advanced Revenue Recovery — Applies deep reimbursement expertise to resolve high-dollar, escalated, and financially significant payer disputes.
• Financial Investigation — Performs detailed claim, payment, and reimbursement analysis to identify variances, exposure, and recovery opportunities.
• Contract Interpretation — Interprets payer contracts, fee schedules, reimbursement methodologies, and payment terms to support dispute resolution.
• Appeals & Escalation Strategy — Develops advanced appeal, redetermination, reconsideration, ALJ, and payer-escalation strategies.
• Strategic Resolution — Evaluates complex fact patterns and develops practical, financially sound approaches to reimbursement disputes.
• Revenue Optimization — Identifies opportunities to recover underpayments, prevent revenue leakage, and strengthen future reimbursement outcomes.
• Advanced Problem Solving — Uses critical thinking, research, and sound judgment to resolve ambiguous or non-routine reimbursement matters.
• Cross-Functional Influence — Coordinates effectively with Revenue Integrity, Legal, Compliance, payer relations, operational leaders, and executive stakeholders.

Essential Duties & Responsibilities

• Complex Recovery Resolution
  • Investigate and resolve high-dollar reimbursement discrepancies, complex denials, underpayments, and payment variances.
  • Manage escalated payer disputes that require advanced research, documentation, negotiation, or cross-functional intervention.
  • Develop and execute recovery strategies for financially significant claims and reimbursement matters.
  • Interpret payer contractual obligations, fee schedules, reimbursement methodologies, and applicable payment terms.
  • Maintain clear documentation of investigation findings, actions taken, payer responses, and resolution outcomes.
• Advanced Appeals & Government Reimbursement
  • Develop and support advanced payer appeals and escalation packages using claim history, documentation, contractual terms, and reimbursement requirements.
  • Manage Medicare redetermination and reconsideration activities and support Administrative Law Judge (ALJ) matters as applicable.
  • Evaluate appeal viability, financial impact, filing requirements, deadlines, and supporting evidence before escalation.
  • Track complex appeal and dispute outcomes and identify recurring payer behaviors or reimbursement risks.
  • Escalate payer compliance or reimbursement concerns when standard recovery channels have been exhausted.
• Financial Analysis & Revenue Protection
  • Perform detailed claim, payment, remittance, contract, and reimbursement audits to identify discrepancies and recovery opportunities.
  • Quantify reimbursement losses, underpayments, financial exposure, and potential recovery value.
  • Develop financial impact assessments to support prioritization, escalation, and leadership decision-making.
  • Identify systemic patterns contributing to high-dollar denials, underpayments, or reimbursement leakage.
  • Recommend corrective actions or process improvements that reduce recurrence and protect future revenue.
• Escalation Management & Cross-Functional Collaboration
  • Serve as an advanced escalation resource for complex reimbursement questions and financially significant cases.
  • Coordinate with Legal, Compliance, payer relations, Revenue Integrity, Billing, Order Management, Finance, and operational leaders when appropriate.
  • Prepare clear case summaries, supporting analysis, and recommended resolution strategies for leadership or executive review.
  • Partner with internal teams to obtain documentation, clarify operational facts, and resolve barriers affecting recovery.
  • Share findings and lessons learned that improve team knowledge and future complex-case resolution.

Key Performance Indicators

Success in this role will be measured against the following KPIs once performance benchmarks and baseline expectations have been established:

• High-Dollar Recovery Value
• Escalation Resolution Rate
• Financial Exposure Mitigation
• Underpayment Recovery

Experience & Education

• Five (5)+ years of advanced healthcare reimbursement, denial management, appeals, underpayment, or revenue recovery experience.
• Demonstrated expertise interpreting payer contracts, fee schedules, reimbursement methodologies, remittance details, and payment variances.
• Experience resolving complex or high-dollar denials, underpayments, payer disputes, and escalated reimbursement matters.
• Working knowledge of Medicare redetermination, reconsideration, and Administrative Law Judge (ALJ) appeal processes preferred.
• Strong analytical and financial review capabilities with the ability to quantify reimbursement exposure and recovery opportunity.
• Ability to synthesize complex claim, payment, contract, and documentation information into clear findings and resolution strategies.
• Strong written and verbal communication skills with the ability to influence payer representatives and internal stakeholders.
• Exceptional critical-thinking, research, organization, and problem-solving skills with strong attention to detail.
• Experience with DME/HME reimbursement, payer portals, revenue cycle systems, reporting tools, and Microsoft Office preferred.