Associate, Healthcare Revenue Cycle Specialist – Disputes, Claims & Investigations

As an Associate, you'll investigate complex hospital and health plan claims to understand how an account moves through billing, claim submission, adjudication, payment, denial, and appeal. You'll identify reimbursement and pricing discrepancies, research the reasons for claim denials, and turn detailed evidence into clear investigative reports and appeal narratives. You'll work with senior consultants and experts to develop evidence-based analyses for payor-provider disputes, including matters involving formal appeals or litigation.

• Trace disputed hospital and health plan claims through coding, billing, submission, payer edits, adjudication, payment posting, denials, recoupments, and appeals to establish the claim history.
• Investigate pricing and reimbursement discrepancies by comparing billed charges, payer contract terms, rate schedules, expected allowed amounts, and actual payments; identify incorrect rates, adjustments, and payment logic.
• Interpret provider agreements, reimbursement policies, and inpatient and outpatient payment methods, including DRG/APR-DRG, APC, case rates, fee schedules, and contractual carve-outs.
• Review UB-04/CMS-1450 and CMS-1500 claims, 837/835 transactions, explanations of benefits, remittance advices, account notes, and payment histories to reconcile claim-level evidence.
• Research denial and adjustment reasons using CARC/RARC codes, payer policies, coding guidance, denial letters, medical records, and prior appeal correspondence; distinguish administrative, contractual, and clinical issues.
• Evaluate disputed claims involving coding, medical necessity, prior authorization, eligibility, coverage, timely filing, DRG downgrades, and recoupments, coordinating with clinical or coding specialists when appropriate.
• Quantify underpayments and other disputed amounts; prepare claim timelines, pricing variance analyses, issue summaries, and exhibits with calculations that can be independently verified.
• Draft evidence-based investigative narratives, claim dispute reports, reconsideration requests, and appeal letters that connect findings to the claim record, contract language, and other supporting evidence in payor-provider disputes.
• Work with hospital revenue cycle and managed care teams, health plan operations, coding specialists, clinicians, counsel, and Stout engagement leaders and/or managers to resolve factual gaps and support dispute strategies.
• Analyze claims populations in Excel, SQL, or other tools to identify patterns of denials and payment errors; maintain organized workpapers and quality-check analyses and written deliverables.

• Bachelor's degree in Accounting, Finance, Health Information Management, Healthcare Administration, Business, or a related field; equivalent directly relevant experience may be considered.
• At least 3 years of hands-on experience in hospital revenue cycle, reimbursement analysis, health plan claims operations, denials management, payment variance investigations, or provider appeals.
• Deep working knowledge of both hospital and payer claims workflows, including claim creation, edits, adjudication, contractual payment, payment posting, denial resolution, and multiple levels of appeal.
• Experience evaluating contractual reimbursement and pricing variances for commercial, Medicare, or Medicaid claims, with an understanding of inpatient and outpatient payment methodologies.
• Ability to interpret institutional and professional claims, 837/835 transactions, EOBs/ERAs, CARC/RARC codes, CPT/HCPCS, ICD-10, revenue codes, modifiers, and DRG/APR-DRG/APC concepts.
• Demonstrated ability to research denial reasons, assess supporting billing and clinical documentation, and write clear, fact-based dispute narratives or payer appeal submissions.
• Advanced Excel and strong written communication skills are required; SQL proficiency or experience with hospital billing and health plan claims platforms is preferred.
• Sound investigative judgment, careful documentation, discretion in handling protected health information, and the ability to manage time-sensitive engagement deadlines.
• Relevant certifications such as CRCR, CHFP, CPC, CCS, RHIA, or RHIT are preferred; experience working with multidisciplinary healthcare or dispute teams is a plus.

• Take ownership of assigned claim investigations, maintain a clear audit trail, and deliver accurate, well-supported work on time.
• Follow the evidence from a payment variance or denial to the underlying contract, policy, transaction, or clinical documentation.
• Write concise narratives that distinguish confirmed findings from open questions and make the supporting calculations and sources easy to review.
• Partner effectively with revenue cycle, coding, clinical, payer, and legal professionals while exercising independent judgment.
• Communicate missing documentation, competing interpretations, and appeal deadlines early so the team can address them.
• Show curiosity and initiative in learning payer rules, reimbursement methods, and the practical operation of claims systems.
• Embody Stout's core values: Positive and Team-Oriented, Accountable, Committed, Relationship-Focused, Super-Responsive, and Great Communicators.
• Demonstrate a commitment to Relentless Excellence® through analytical rigor, professional integrity, and exceptional client service.

The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements and criteria necessary to successfully perform the job.