Denial Management Specialist

Essential Duties & Responsibilities

• Review and work denied and rejected claims.
• Determine the root cause of each denial.
• Review EOBs, ERAs, CARC/RARC codes, payer policies, and claim history.
• Correct and resubmit claims when appropriate.
• Prepare reconsiderations, first-level appeals, and subsequent appeals.
• Submit supporting medical records and documentation.
• Contact insurance companies regarding denied or incorrectly processed claims.
• Monitor appeals through final determination.
• Research unpaid and underpaid claims.
• Identify potential payer underpayments.
• Request claim reprocessing when appropriate.
• Resolve coordination-of-benefits and payer sequencing issues.
• Monitor timely-filing and appeal deadlines.
• Work high-dollar and complex outstanding claims.
• Document all activity accurately in the appropriate system.
• Coordinate with Medical Billing and A/R staff to resolve account issues.
• Communicate coding or documentation concerns to the appropriate department.
• Identify recurring denial patterns.
• Report significant payer trends to the Operations Manager.
• Recommend process changes to prevent future denials.
• Assist with A/R follow-up when necessary.

Denial Prevention

An important part of this position is not simply fixing denials after they happen.

The Denial Management Specialist will analyze denial trends and work with the Operations Manager and billing team to prevent recurring denials.

This includes identifying problems involving:

• Eligibility
• Prior authorization
• Provider enrollment
• Coding/modifiers
• Claim formatting
• Timely filing
• Medical necessity
• Duplicate claims
• Coordination of benefits
• Provider information
• Documentation
• Payer-specific billing requirements

Qualifications

• Minimum 2 years of medical billing, denial management, insurance follow-up, or healthcare revenue cycle experience preferred.
• Strong experience working insurance denials and appeals.
• Knowledge of Medicare, Medicaid, Medicare Advantage, Medicaid Managed Care, and commercial insurance.
• Understanding of CMS-1500 claims.
• Working knowledge of CPT, HCPCS, ICD-10-CM, and modifiers.
• Experience interpreting EOBs and ERAs.
• Familiarity with CARC and RARC denial codes.
• Experience using insurance portals and clearinghouses.
• Ability to research payer policies independently.
• Excellent written communication skills for appeals.
• Strong analytical and problem-solving abilities.
• Excellent attention to detail.

Preferred Qualifications

• Experience working for an RCM or medical billing company.
• CPC, CPB, CRCR, or similar certification.
• Experience managing high-dollar and aged A/R.
• Medicare and Medicaid experience.
• Experience with multiple medical specialties.
• Experience using multiple EHR/Practice Management platforms.
• Bilingual English/Spanish is a plus.

Performance Expectations

Performance may be evaluated based on:

• Denial resolution rate
• Appeal/reconsideration completion
• Reimbursement recovered
• Reduction in recurring denials
• Timely-filing protection
• A/R reduction
• Quality and accuracy
• Appropriate account documentation
• Productivity
• Identification of denial trends
• Implementation of denial-prevention opportunities

Position Summary

AdvantixxRCM is seeking an experienced Denial Management Specialist to manage denied, rejected, underpaid, and complex insurance claims.

This position is responsible for identifying the root cause of claim denials, correcting billing issues, preparing appeals and reconsiderations, communicating with insurance companies, and pursuing claims through final resolution.

The ideal candidate understands medical billing and insurance reimbursement and is comfortable independently researching complex claim issues involving Medicare, Medicaid, Medicare Advantage, Medicaid Managed Care, and commercial insurance.