Denials Management and Claims Resolution

Job Description

Job Description

JOB TITLE: Denials Management & Claims Resolution Specialist

REPORTS TO: Revenue Cycle Manager

FLSA STATUS: Non-Exempt

JOB SUMMARY:

The Denials Management & Claims Resolution Specialist is responsible for identifying, investigating, appealing, and resolving denied or rejected insurance claims to maximize reimbursement and reduce accounts receivable. This position works closely with providers, coding, billing, and payer representatives to resolve claim issues, identify denial trends, and improve revenue cycle performance. The specialist ensures compliance with payer guidelines while supporting timely and accurate reimbursement.

QUALIFICATIONS/EDUCATION:

• High School Diploma required.
• Minimum of two (2) years of experience in medical billing, collections, denial management, or claims resolution.
• Experience with insurance appeals, denial management, and payer follow-up required.
• Knowledge of Medicare, Medicaid, and commercial insurance billing guidelines.
• Bilingual English/Spanish preferred; must be able to read, write, and speak English.
• Basic computer knowledge including Microsoft Word, Excel, Electronic Health Records (EHR), billing software, payer portals, email, and e-fax systems.

CERTIFICATIONS/LICENSES:

• CPC preferred

ABILITIES/SKILLS:

• In-depth knowledge of CPT, ICD-10, HCPCS, CMS-1500 claim forms, medical terminology, and payer billing requirements.
• Strong understanding of denial management, claims resolution, reimbursement methodologies, and insurance appeals.
• Knowledge of Medicare, Medicaid, and commercial payer policies.
• Excellent analytical and problem-solving skills.
• Strong organizational skills with the ability to prioritize multiple accounts and meet appeal deadlines.
• Excellent written and verbal communication skills.
• Ability to work independently with minimal supervision.
• Ability to maintain patient confidentiality and comply with HIPAA regulations.
• Demonstrates proficiency in Electronic Health Records (EHR), billing software, Microsoft Office, and payer portals.
• Must be dependable, detail-oriented, and able to follow company policies and procedures.

SUPERVISORY RESPONSIBILITIES:

N/A

ESSENTIAL DUTIES/ RESPONSIBILITIES:

• Investigate, analyze, and resolve denied, rejected, and underpaid insurance claims.
• Prepare, submit, and track first-level and subsequent insurance appeals within payer deadlines.
• Review medical records, coding, documentation, and billing information to determine the cause of claim denials.
• Identify denial trends and recommend corrective actions to reduce future denials and improve reimbursement.
• Communicate with insurance companies to resolve claim payment issues and obtain claim status updates.
• Work collaboratively with providers, coders, billers, and authorization staff to resolve documentation, coding, and billing deficiencies.
• Request claim adjustments, corrected claims, or reconsiderations as appropriate to resolve outstanding balances.
• Monitor accounts receivable and prioritize denied claims based on aging and financial impact.
• Maintain accurate and detailed account notes and documentation within the billing system.
• Ensure all denial and appeal activities comply with payer guidelines and regulatory requirements.
• Prepare denial management and appeals activity reports for the Revenue Cycle Manager.
• Assist with identifying process improvements to enhance claim acceptance rates and reduce reimbursement delays.
• Perform other duties as assigned by management.

• Successful completion of a criminal background check .
• Successful completion of professional reference checks .

We offer a competitive salary and a comprehensive benefits package, including:

• 100% employer-paid employee health insurance
• Dental Insurance
• Vision Insurance
• Life Insurance
• 401(k) Retirement Plan
• Paid Time Off (PTO)
• Paid Holidays