Denial Resolution Specialist

Denial Resolution Specialist

The Denial Resolution Specialist is responsible for the timely review, resolution, and prevention of denied claims to maximize reimbursement and reduce revenue leakage. This role works within MEDITECH denial work queues (DEN-*) and serves as a subject matter expert in payer rules, denial trends, and appeals processes. The Denial Resolution Specialist directly impacts the organization's financial health by recovering revenue that would otherwise be lost. This role also drives long-term improvement by identifying and addressing the root causes of denials, reducing rework, and improving overall revenue cycle performance. The Denial Resolution Specialist plays a key role in reducing denial rates, recovering revenue, and identifying root causes to prevent future denials.

Denial Resolution Specialist (Primary Function)

• Review denied claims in MEDITECH denial work queues:
• DEN-ELIG-*, DEN-AUTH-*, DEN-CODING-*, DEN-MEDNEC-*, DEN-TIMELY-*
• Analyze Explanation of Benefits (EOB) / Electronic Remittance Advice (ERA) and payer codes (CARC/RARC).
• Take appropriate action:
• Correct and resubmit claims.
• Submit reconsiderations or formal appeals.
• Request additional documentation.
• Ensure all denials are worked within established SLA (typically =5 days).

Appeals Management

• Prepare and submit first-level and second-level appeals.
• Gather and review:
• Medical records.
• Coding documentation.
• Authorization details.
• Track appeal status and follow through to resolution.
• Escalate complex or high-dollar cases as needed.

Work Queue Management

• Maintain assigned denial queues by:
• Working accounts daily.
• Meeting productivity targets.
• Preventing backlog accumulation.
• Prioritize:
• High-dollar claims.
• Timely filing deadlines.
• Aging denials.

Payer Communication

• Contact insurance companies as needed to:
• Clarify denial reasons.
• Request reconsideration.
• Verify appeal requirements.
• Maintain knowledge of payer-specific policies and updates.

Documentation & Compliance

• Accurately document all actions taken on accounts.
• Ensure compliance with:
• CMS guidelines.
• Payer contracts and requirements.
• Organizational policies.
• Maintain regular and predictable attendance.
• Performs other essential duties as assigned.

Requirements

Education/Experience/Skill Requirements

• High school diploma or equivalent required.
• Bachelor's degree is preferred.
• 3+ years of healthcare billing or revenue cycle experience.
• Experience working in an EHR system (MEDITECH preferred).
• Experience working in clearinghouse (SSI Preferred).
• Strong understanding of:
• Insurance billing and claims lifecycle
• EOB/ERA interpretation
• Payer rules and denial codes
• Prior experience in denial management or appeals.
• Analytical and critical thinking skills.
• Strong attention to detail.
• Problem-solving and root cause identification.
• Effective communication and negotiation skills.
• Ability to manage high volumes and deadlines.
• Performance Metrics
• Denial resolution rate.
• Appeal success rate.
• Average days to work denials (=5 days target).
• Reduction in repeat denials by category.
• Work queue volume and aging.

Physical/Mental Requirements

• Must be able to sit and stand, intermittent 8 to 10 hours a day.
• Must be able to use standard office equipment, including the telephone and computer keyboard.
• Continuously works under pressure of near 100% accuracy while meeting inflexible deadlines.
• Continuously utilizes manual/bi-manual dexterity, near vision, speech, and hearing.
• Frequently stands, walks, sits and utilizes eye/hand coordination and color definition.
• Occasionally reaches above shoulder, regularly required to lift and/or carry up to 40 lbs.
• Occasionally walks on uneven surfaces.