Reimbursement Specialist, Appeals

Job Responsibilities

• Investigate denials, prepare and submit appeals, and following up with payors to ensure timely and accurate reimbursement.
• Contact insurance companies and utilize payor portals to investigate denials, determine next steps, and perform appeals follow-up.
• Review and interpret Explanation of Benefits (EOBs) to determine allowances and identify root causes of denials.
• Manage various denial types that may result in low-pay appeals, prior authorizations, Clinical and Administration Level 1 and Level 2 appeals.
• Submit corrected claims and appeals in accordance with payer guidelines and timelines.
• Asses denied cases and prepare higher-level appeals for compelling cases for the leadership review and submission when required.
• Maintain accurate documentation of denials, appeals actions, and payer communications.
• Assist in developing and maintaining payer-specific appeals workflows and documentation requirements.
• Communicate with patients and providers regarding appeals-related billing questions, EOBs, and financial responsibility in complex or escalated cases.
• Critically assess challenging situations and escalate to the Supervisor or leadership when appropriate.
• Prioritize multiple concurrent appeals and operate with a sense of urgency.

Job Qualifications

• 4+ years of experience in reimbursement, denials management, or revenue cycle management within a diagnostics company, laboratory, or commercial payer environment.
• Bachelor's degree or equivalent experience.
• Strong understanding of medical benefit structures, including Federal, State, PPO, HMO, and indemnity plans.
• Working knowledge of CPT, ICD-10, and HCPCS coding, as well as LCD/NCD coverage and reimbursement guidelines.
• Proven ability to analyze denials, identify root causes, and resolve issues effectively.
• Excellent verbal and written communication skills with a customer service mindset.
• Strong troubleshooting, organizational, and time-management skills.
• Ability to adapt to changes.
• Experience with Prior Authorizations preferred.
• Experience with a billing vendor (e.g., Xifin, Quadax, or Telcor) preferred.