Description

Salary Range: $33.17 - $48.08
Position Summary

The Billing Denials Specialist is responsible for managing the end-to-end denial and appeals process for the organization, including identifying, tracking, analyzing, and resolving payer claim denials. This role prepares and submits timely, well-supported appeals; partners with clinical, coding, billing, and payer-relations staff to reduce future denials; and monitors trends to drive process improvements. The Specialist plays a key role in protecting revenue integrity while ensuring all activities comply with payer, state, and federal regulations.

Statement of Accountability

Reports to: Manager of Billing Denials and Appeals

Qualifications
• Education
• Licensure
• Work Experience
• Skills/computer/ specific technical

§ Other qualifications, miscellaneous

Specify if qualifications are Required or Preferred
• Associate's or Bachelor's degree in Health Information Management, Healthcare Administration, Nursing, or a related field preferred; equivalent work experience considered.
• Minimum of 2-4 years of experience in medical billing, claims denial management, appeals, utilization review, or revenue cycle operations.
• Working knowledge of ICD-10, CPT, and HCPCS coding, medical terminology, and payer reimbursement methodologies.
• Familiarity with Medicare, Medicaid, and commercial payer denial and appeal guidelines.
• Certified Coding Specialist (CCS), Certified Professional Coder (CPC), or Certified Revenue Cycle Representative (CRCR) credential a plus.
• Proficiency with electronic health record (EHR) and practice management/billing systems.
• Strong written and verbal communication skills, with the ability to construct clear, evidence-based appeal letters.

Essential Job Responsibilities

Achieving Results

Key Components: assess, plan, evaluate, demonstrate initiative, quality of work, productivity
• Meets or exceeds established productivity and turnaround-time targets for denial resolution and appeal submission.
• Successfully overturns a measurable percentage of denied claims through accurate, well-documented appeals.
• Prioritizes workload effectively to meet payer-specific filing deadlines and avoid timely-filing losses.
• Tracks outcomes and follows through until each denial is resolved, escalated, or closed appropriately.

Demonstrates Skill

Key Components: competency, job knowledge, organizational skills, analytical skill, management of information, employee & patient safety
Technical Expertise
• Expert-level understanding of denial types (clinical necessity, coding, authorization, timely filing, COB) and corresponding appeal strategies.
• Strong command of payer contracts, fee schedules, and reimbursement logic across Medicare, Medicaid, and commercial lines of business.
• Proficiency in hospital billing and revenue cycle systems (Epic) and payer web portals.
• Familiarity with denial management and workflow automation platforms (e.g., Kodiak, Optum360, Availity).
• Working knowledge of clinical documentation requirements, ICD-10-CM/PCS coding principles, and clinical criteria sets (InterQual, Milliman).

Planning & Coordinating

Key Components: delegates, decision making, problem solving, management of resources
• Organizes and manages a high-volume caseload of denials and appeals to ensure timely, orderly processing.
• Coordinates with coding, clinical documentation, case management, and billing teams to gather supporting documentation.
• Maintains an organized tracking log or dashboard of denial status, appeal deadlines, and outcomes.
• Schedules and leads regular denial-trend review meetings with relevant stakeholders.

Professionalism

Key Components: dependability, interpersonal skills, teamwork, patient first ethic, customer service, communication skills, punctuality/attendance, receptiveness to criticism, judgment, confidentiality
• Maintains confidentiality of patient information in accordance with HIPAA and organizational policy.
• Communicates respectfully and collaboratively with payers, providers, and internal departments.
• Represents the organization professionally in all written and verbal payer interactions.
• Exercises sound judgment and integrity when handling sensitive financial and clinical information.