Medical Claims Denial

Overview

A Healthcare Claims Denial Management Specialist is responsible for identifying,

analyzing, and resolving denied or underpaid medical insurance claims. This role ensures

accurate reimbursement by working with payers, internal billing teams, and healthcare

providers while maintaining compliance with regulatory and payer-specific requirements.

Onsite in Addison, TX

Starting Pay - $27-28/hr

Great company and culture

Key Responsibilities

Denial Review & Resolution

• Review and analyze denied, underpaid, and rejected medical claims to determine root causes.
• Correct claim errors, update coding or documentation as needed, and resubmit claims to payers within required timeframes.
• Follow up with insurance companies to resolve outstanding denials and secure payment.

Payer Communication & Documentation

• Communicate directly with insurance representatives to verify claim status, obtain clarification, and resolve discrepancies.
• Maintain detailed documentation of actions taken, correspondence, and outcomes

in billing and practice management systems.

Root Cause Analysis & Prevention

• Identify denial patterns or trends across payers, coding categories, or service lines.
• Collaborate with coding, billing, and clinical teams to prevent future denials through

process improvements, training, or documentation enhancements.

Appeals Management

• Prepare and submit formal appeals with supporting medical records, coding

references, and payer policy documentation.

• Track appeal outcomes and ensure compliance with appeal deadlines and payer

regulations.

Compliance & Quality Assurance

• Ensure all claim corrections and submissions comply with federal, state, and payer-specific

regulations.

• Stay up to date on payer policy changes, coding guidelines (CPT, HCPCS, ICD-10),

and industry best practices.

• Reporting & Performance Tracking

Generate denial reports, analyze denial metrics, and provide insights to leadership.

• Monitor key performance indicators (KPIs) such as denial rate, appeal success rate,

and days in accounts receivable (A/R).

Required Skills & Qualifications

Experience: 2–4 years in medical billing, claims processing, or denial management

(healthcare or payer environment).

Knowledge: Revenue cycle processes

CPT/HCPCS and ICD-10 coding

Insurance payer rules (commercial, Medicare, Medicaid)

Medical terminology

Technical Skills: Proficiency with EMR/EHR systems, clearinghouses, and billing

software.

Analytical Abilities: Strong attention to detail, ability to identify trends, solve

problems, and interpret payer policies.

Communication: Excellent verbal and written communication skills for working

with payers, providers, and internal teams.

Organizational Skills: Ability to manage multiple priorities, meet deadlines, and

maintain thorough records.

Preferred Qualifications

• CPC, CPB, or other AAPC/AHIMA certification.
• Experience with high-volume claims environments.
• Familiarity with appeals and audit processes.