Denials & Appeals Specialist RCM

The primary responsibility of the RCM Reimbursement Specialist for Appeal and Denial is to maximize reimbursement by collecting outstanding balances from insurance companies. The Specialist will maximize collections by following up on unresolved claims and appeals, and by escalating claims for reconsiderations and up to three levels of appeals. The Specialist will work closely with the Market Access and RCM Management to ensure coverage and appropriate reimbursement from contracted and non-contracted payers and government health plans.

This role requires meticulous work and the ability to thrive in a fast-paced environment.

This is a full-time position, Monday through Friday, with occasional overtime as needed.

Responsibilities

• Resolve aged claims and appeals without payer responses via payer portals & outbound phone calls.
• Identify claims that need a first, second, or third-level appeal.
• Assist teammates with projects and denial work queue management.
• Prioritize an assigned work queue to ensure timely work is balanced with working the most payable claims.
• Identify non-payment trends and, in collaboration with Revenue Cycle leadership, escalate groups of claims to the Market Access team.
• Investigate denial and non-payment trends identified by the Revenue Cycle Analytics team. Propose solutions and collaborate cross-functionally with the Market Access and Management
• Share opportunities to improve upstream work to prevent denials.
• Work with patients when their assistance is needed in the appeal process.
• Work professionally with Revenue Cycle teammates to be responsive to requests that require your assistance.
  
  

Qualifications

• College degree preferred or equivalent experience of 5 plus years
• 5 years’ experience in medical billing; strong preference will be given to candidates with molecular laboratory billing experience. Medical billing experience may be substituted for a bachelor’s degree.
• Understanding of patient protections under HIPAA and proper handling of protected health information (PHI).
• Working knowledge of health insurance and terminology.
• Excellent communication and people skills.
• Meticulous with strong analytical and problem-solving abilities.
  
  

Skills

• Strong knowledge of insurance guidelines, CPT/ICD-10 codes, and medical terminology.
• Excellent attention to detail and time management skills.
• Effective communication and problem-solving abilities.
• Proficiency in Microsoft Office Suite and healthcare software tools.