Billing Denials Specialist

Qualifications

·Education

·Licensure

·Work Experience

·Skills/computer/ specific technical

§Other qualifications, miscellaneous

Specify 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 Results

Key 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 Skill

Key Components: competency, job knowledge, organizational skills, analytical skill, management of information, employee & patient safety

Technical Expertise

Expert-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 & Coordinating

Key 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.

Professionalism

Key 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.