Revenue Cycle Specialist II

Employment Type: Full-Time, M-F hybrid role

Reports to: Director of Revenue Cycle Management

The Denials Specialist/Revenue Cycle Specialist II is essential for revenue cycle management, ensuring healthcare providers receive appropriate payment by correcting billing errors and addressing claim denials in accordance with payer guidelines, protecting revenue and enhancing efficiency.

Responsibilities:

• Review and analyze unpaid and denied insurance claims to determine root causes, including coding inaccuracies, billing errors, authorization deficiencies, eligibility issues, payer policy conflicts, and medical necessity determinations, ensuring appropriate corrective action is identified.

• Research and interpret payer policies, contracts, coverage determinations, and clinical guidelines to support claim corrections and appeal strategies, including Medicare, Medicaid, and commercial insurance requirements.

• Prepare, submit, and track appeals, reconsiderations, and corrected claims in a timely and accurate manner, ensuring all submissions meet payer-specific documentation, formatting, and deadline requirements.

• Communicate directly with insurance carriers via phone, payer portals, and written correspondence to clarify denial reasons, obtain claim status updates, and advocate for appropriate reimbursement.

• Collaborate closely with coding, billing, and clinical teams to obtain, review, and submit supporting medical documentation, physician statements, and corrected coding as needed to support appeals.

• Maintain thorough and accurate documentation of all denial resolutions, appeal submissions, payer communications, and outcomes within the billing system to ensure audit readiness and reporting accuracy.

• Monitor claims filing and deadlines, payer response timelines, and follow-up requirements to ensure compliance with contractual, regulatory, and payer-specific timeframes.

• Identify recurring denial trends and systemic issues, analyze their financial and operational impact, and escalate findings to leadership with recommendations for process improvements and denial prevention strategies.

• Assist with denial prevention initiatives by providing feedback, education, and workflow recommendations to billing, coding, and clinical staff to reduce future denials.

• Stay current on federal and state regulations, CMS guidelines, and individual insurance company policies to ensure compliance and support accurate claims processing.

• Maintain detailed documentation of all claim actions, payer communications, and appeal outcomes to support audits and reporting.?

Qualifications:

• 5-10 years in medical billing and claim denial management.

• Strong proficiency in Microsoft 365 (Outlook, Word, Excel, Teams, etc.), with the ability to quickly adapt to new tools and systems.

• Working knowledge of payer regulations and hospital billing processes.

• Familiarity with CPT, ICD-10, and HCPCS coding concepts.

• Experience using electronic health record (EHR) and/or medical billing software.

• Excellent verbal and written communication skills.

• Exceptionally proactive, organized, and detail oriented.