Reimbursement Specialist - Appeals

Job Responsibilities

Reporting to the Reimbursement Supervisor – Back End, this role supports the Reimbursement department with a focus on claims denials, underpayments, and appeals resolution. This position is responsible for investigating denials, preparing and submitting appeals, and following up with payers to ensure timely and accurate reimbursement.

Manage various denial types that may result in low-pay appeals, Level 1 appeals, and Level 2 appeals.

Prepare higher-level appeals for leadership review and submission when required.

Review and interpret Explanation of Benefits (EOBs) to determine contractual allowances and identify root causes of denials.

Contact insurance companies and utilize payer portals to investigate denials, determine next steps, and perform appeals follow-up.

Submit corrected claims and appeals in accordance with payer guidelines and timelines.

Maintain accurate documentation of denials, appeals actions, and payer communications.

Assist in developing and maintaining payer-specific appeals workflows and documentation.

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.

Ensure compliance with all applicable billing regulations and company policies, including HIPAA.

Comply with all Federal and State regulations related to billing and reimbursement.

Prioritize multiple concurrent appeals and operate with a sense of urgency.

Requirements

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.

Experience with Xifin, Quadax, or Telcor preferred.

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.

Strong attention to detail, judgment, and follow-through.

Excellent verbal and written communication skills with a customer service mindset.

Strong troubleshooting, organizational, and time-management skills.

Ability to adapt to changing business needs.

Self-starter who can work independently.

Compliance Responsibilities

Health Insurance Portability and Accountability Act (HIPAA) is a federal law that describes the national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge.

All roles at Naveris require compliance with legal and regulatory requirements of HIPAA and acceptance and adherence to all policies and standards at Naveris.

Personnel acknowledges they are personally responsible for reporting any suspected violations or abuse and are required to complete HIPAA training when joining the company.