CPC Denials Escalation Analyst

Claims A/R and Denial Analyst Escalations CPC Lead

This position requires strong expertise in coding guidelines, payer policy, denials management, and claims processing. The Claims CPC A/R and Denial Analyst Escalations Lead will serve as a subject-matter expert on denied-claim escalations, contribute to denial-prevention strategies, perform chart reviews, and ensure claims are properly adjudicated for payment. The role supports complex A/R projects, denial coding reviews, and compliance audits while maintaining productivity and quality standards aligned with regulatory and organizational requirements.

Essential Responsibilities:

The responsibilities of the Claims A/R and Denial Analyst Escalations CPC Lead will include:

• Serve as subject matter expert (SME) for escalated claim denials from vendors and internal RCM teams.
• Master claim denials and claims processing to support denial prevention strategies and drive claim resolution to payment.
• Review coding-related denials for potential correction and resubmission.
• Work assigned high-level A/R projects and complex claim investigations.
• Maintain adherence to quality and productivity standards established by the organization and industry guidelines.
• Follow up on escalated or project-related claims, working no fewer than 6570 claims per day.
• Identify denial and payer trends and communicate findings to AR management and senior leadership.
• Conduct follow-up with Medicare and Commercial insurance payers on escalated claims.
• Perform coding, billing, and documentation compliance audits within established timelines.
• Assist in identifying the need for payer policy updates or process changes to support regulatory compliance and claim payment.
• Prepare reports summarizing audit findings and recommendations for operational improvement.
• Participates in special projects as assigned.
• Any other duties as assigned.

Essential Skills:

The Claims A/R and Denial Analyst Escalations CPC Lead must be extremely detail oriented. The Claims A/R and Denial Analyst Escalations CPC Lead must be able to comprehend all issues and be able to articulate those issues to any involved person(s) needed to assist in their complete resolution. He/she must also possess:

• Advanced analytical and reporting skills
• Demonstrated ability to lead cross-functional initiatives
• Basic understanding of rudimentary medical terminology.
• Excellent judgement and decision making.
• Problem solving and organizational skills.
• Reliability, Accuracy and Efficiency when dealing with patients or third-party payors.
• Excellent verbal and written communication skills.
• Ability to use good judgments in highly emotional and demanding situations.
• Ability to react to frequent changes in duties and volume of work.
• Ability to manage multiple tasks with ease and efficiency.
• Ability to work independently with minimal supervision and be result oriented.
• Effective interpersonal skills, including the ability to promote teamwork.
• Strong problem-solving skills.
• Ability to ensure a high level of customer satisfaction including employees, patients, physicians, and external stakeholders.
• Maintains confidentiality of sensitive information
• Broad knowledge of health care business office practices and principles

Key Performance Indicators (KPIs):

Daily Productivity:

o Work 6570 escalated claims per day (approximately 325350 per week).

Escalated Claim Resolution Rate:

o Maintain a resolution rate of ?95% for escalated claims.

Denial Overturn Rate:

o Achieve ?92% successful reversal of denied claims.

Escalation Aging Control:

o Address 95% of escalated claims within 1 business day.

Monthly Cash Recovery Influence:

o Contribute to $350K$400K in recovered or corrected claim payments monthly.

Coding Denial Accuracy:

o Maintain ?95% accuracy in coding denial review and correction.

Denial Trend Identification:

o Identify and report at least 3 denial trends monthly to leadership.

Audit Completion Timeliness:

o Complete 100% compliance audits within the scheduled timeframe.

Escalation Response Time:

o Provide SME guidance on escalated claims within 48 hours.

Compliance Adherence:

o Maintain 100% compliance with CMS, payer, and regulatory coding standards.

Operational Improvement Contribution:

o Recommend at least 2 process improvements per quarter based on denial trend analysis.

Education and Experience Required:

CPC, CPB or AHIMA associates degree

5+ years Revenue Cycle Management experience

Strong understanding of CPT, HCPCS, and charge capture workflows

Experience with Athena, Epic, or comparable PM/EHR systems

Supervisory responsibility: No

Work Environment

This role routinely uses standard office equipment such as computers, phones, photocopiers, scanning, filing cabinets and fax machines.

Dress attire required: Determined by the local office.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

While performing the duties of this job, the employee is regularly required to see, talk or hear. The employee frequently is required to stand; walk; use hands to finger, handle or feel; and reach with hands and arms.

This position requires the ability occasionally to lift office products and supplies, up to 20 pounds.

Days/Hours

This is a full-time position, and hours of work 8:30am-5:00pm and days are Monday through Friday, this salaried, exempt position may require occasional work beyond standard business hours to meet deadlines, meetings, and organizational objectives.

Travel Minimal 3

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Signatures

Manager Date

HR Date

Employee signature below constitutes employee's understanding of the requirements, essential functions and duties of the position.

Employee

Monday-Friday 8:30am-5:00pm