Billing Denials Specialist

Billing Denials Specialist

Salary Range: $33.17 - $48.08

Position Summary - The Billing Denials Specialist is responsible for managing the end-to-end denial and appeals process for the organization, including identifying, tracking, analyzing, and resolving payer claim denials. This role prepares and submits timely, well-supported appeals; partners with clinical, coding, billing, and payer-relations staff to reduce future denials; and monitors trends to drive process improvements. The Specialist plays a key role in protecting revenue integrity while ensuring all activities comply with payer, state, and federal regulations.

Statement of Accountability - Reports to: Manager of Billing Denials and Appeals

QualificationsEducationLicensureWork ExperienceSkills/computer/ specific technicalOther qualifications, miscellaneousSpecify if qualifications are Required or Preferred - Associate's or Bachelor's degree in Health Information Management, Healthcare Administration, Nursing, or a related field preferred; equivalent work experience considered.Minimum of 2-4 years of experience in medical billing, claims denial management, appeals, utilization review, or revenue cycle operations.Working knowledge of ICD-10, CPT, and HCPCS coding, medical terminology, and payer reimbursement methodologies.Familiarity with Medicare, Medicaid, and commercial payer denial and appeal guidelines.Certified Coding Specialist (CCS), Certified Professional Coder (CPC), or Certified Revenue Cycle Representative (CRCR) credential a plus.Proficiency with electronic health record (EHR) and practice management/billing systems.Strong written and verbal communication skills, with the ability to construct clear, evidence-based appeal letters.

Essential Job Responsibilities

Achieving ResultsKey Components: assess, plan, evaluate, demonstrate initiative, quality of work, productivity - Meets or exceeds established productivity and turnaround-time targets for denial resolution and appeal submission.Successfully overturns a measurable percentage of denied claims through accurate, well-documented appeals.Prioritizes workload effectively to meet payer-specific filing deadlines and avoid timely-filing losses.Tracks outcomes and follows through until each denial is resolved, escalated, or closed appropriately.

Demonstrates SkillKey Components: competency, job knowledge, organizational skills, analytical skill, management of information, employee & patient safety - Technical ExpertiseExpert-level understanding of denial types (clinical necessity, coding, authorization, timely filing, COB) and corresponding appeal strategies.Strong command of payer contracts, fee schedules, and reimbursement logic across Medicare, Medicaid, and commercial lines of business.Proficiency in hospital billing and revenue cycle systems (Epic) and payer web portals.Familiarity with denial management and workflow automation platforms (e.g., Kodiak, Optum360, Availity).Working knowledge of clinical documentation requirements, ICD-10-CM/PCS coding principles, and clinical criteria sets (InterQual, Milliman).

Planning & CoordinatingKey Components: delegates, decision making, problem solving, management of resources - Organizes and manages a high-volume caseload of denials and appeals to ensure timely, orderly processing.Coordinates with coding, clinical documentation, case management, and billing teams to gather supporting documentation.Maintains an organized tracking log or dashboard of denial status, appeal deadlines, and outcomes.Schedules and leads regular denial-trend review meetings with relevant stakeholders.

ProfessionalismKey Components: dependability, interpersonal skills, teamwork, patient first ethic, customer service, communication skills, punctuality/attendance, receptiveness to criticism, judgment, confidentiality - Maintains confidentiality of patient information in accordance with HIPAA and organizational policy.Communicates respectfully and collaboratively with payers, providers, and internal departments.Represents the organization professionally in all written and verbal payer interactions.Exercises sound judgment and integrity when handling sensitive financial and clinical information.

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