Job Description

Position Summary

The Denials Specialist is responsible for analyzing, appealing, and resolving denied or underpaid insurance claims. This role requires a detailed understanding of payer policies, strong follow-up skills, and collaboration across billing, coding, and clinical teams to reduce denial rates, secure reimbursement, and improve cash flow.

Key Responsibilities

Denial Analysis & Resolution

• Review and categorize denied claims by payer, denial reason, and service type.
• Investigate root causes of denials and identify trends.
• Correct errors and resubmit claims in a timely manner.
• Draft and submit clear, evidence-based appeals to payers.

Payer Follow-Up

• Contact insurance companies to resolve claim denials, underpayments, or pending claims.
• Maintain up-to-date knowledge of payer policies and medical necessity guidelines.
• Escalate recurring payer issues to leadership for resolution.

Collaboration & Documentation

• Work with billing, coding, and clinical staff to prevent future denials.
• Document all actions taken in the practice management/RCM system.
• Maintain thorough records of appeals, outcomes, and correspondence.

Performance Monitoring

• Track denial overturn rates, recovery amounts, and appeal success rates.
• Provide feedback to leadership on denial trends and prevention strategies.
• Assist in staff education on payer rules and common denial issues.

Qualifications

• High school diploma or equivalent required; Associate’s or Bachelor’s degree in Healthcare, Business, or related field preferred.
• 2+ years of experience in medical billing, claims processing, or denial management.
• Knowledge of payer requirements, CPT/HCPCS coding, and EOB/ERA interpretation.
• Strong written and verbal communication skills for effective appeal letters and payer calls.
• Proficiency in EHR/RCM software and Microsoft Office Suite.
• Detail-oriented with strong problem-solving and time-management skills.

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