Position Summary
The Denial Recovery Specialist is responsible for reviewing, analyzing, and resolving denied professional billing claims to ensure accurate and timely reimbursement. This role focuses on identifying root causes of denials, initiating corrective actions, and collaborating with coding, billing, and payer representatives to maximize revenue recovery and reduce future denials.
The ideal candidate demonstrates strong, payer knowledge, and a deep understanding of physician billing guidelines, reimbursement methodologies and analytical skills.
Key Responsibilities
Denial Resolution & Appeals
- Review denied professional claims to determine root cause and appropriate resolution.
- Research payer policies, contracts, and billing guidelines to support appeals.
- Prepare and submit timely, well-documented appeals and reconsiderations.
- Follow up with payers to ensure proper adjudication and payment.
- Track appeal outcomes and identify trends in overturn rates.
Accounts Receivable Management
- Manage assigned A/R workqueues to ensure timely follow-up.
- Prioritize high-dollar and aging claims to optimize cash flow.
- Monitor denial aging and escalate unresolved issues appropriately.
Root Cause Analysis & Prevention
- Identify trends in denials by payer, provider, specialty, CPT, or diagnosis and escalate to management.
- Collaborate with coding and billing teams to address documentation or submission errors.
- Provide feedback to front-end and coding teams to prevent recurring denials.
- Assist in developing process improvements to improve clean claim rates.
Compliance & Accuracy
- Ensure all billing and appeal activities comply with CMS, Medicare, Medicaid, and commercial payer regulations.
- Maintain accurate documentation of actions taken on accounts.
- Protect patient confidentiality in accordance with HIPAA guidelines.
Reporting & Performance Monitoring
- Track and maintain users own productivity and quality metrics.
- Participate in team meetings and training initiatives.
Qualifications
Education
- High school diploma required
- Associate or Bachelor’s degree in Healthcare Administration, Business, or related field preferred
Experience
- 3–5 years of professional medical billing or denial management experience
- Strong knowledge of CPT, ICD-10, HCPCS billing or coding fundamentals
- Experience working with Medicare, Medicaid, and commercial payers
- Familiarity with Epic EHR system
- Clinical, CPC or RN background experience preferred
Core Competencies
- Analytical and problem-solving skills
- Knowledge of payer guidelines and reimbursement methodologies
- Detail-oriented with strong documentation skills
- Effective written and verbal communication
- Ability to manage productivity goals and meet deadlines
- Team-oriented with a proactive approach