Job Description

Working as an advanced individual contributor and escalation resource, the Complex Revenue Recovery Specialist performs detailed claim and payment audits, interprets payer contracts and fee schedules, quantifies financial exposure and recovery opportunities, develops strategic resolution approaches, and coordinates complex escalations with Legal, Compliance, payer relations, operational leaders, and executive stakeholders when appropriate. The position directly supports revenue protection by resolving high-risk reimbursement issues and identifying systemic opportunities to prevent recurrence.

Core Competencies

• Advanced Revenue Recovery — Applies deep reimbursement expertise to resolve high-dollar, escalated, and financially significant payer disputes.

• Financial Investigation — Performs detailed claim, payment, and reimbursement analysis to identify variances, exposure, and recovery opportunities.

• Contract Interpretation — Interprets payer contracts, fee schedules, reimbursement methodologies, and payment terms to support dispute resolution.

• Appeals & Escalation Strategy — Develops advanced appeal, redetermination, reconsideration, ALJ, and payer-escalation strategies.

• Strategic Resolution — Evaluates complex fact patterns and develops practical, financially sound approaches to reimbursement disputes.

• Revenue Optimization — Identifies opportunities to recover underpayments, prevent revenue leakage, and strengthen future reimbursement outcomes.

• Advanced Problem Solving — Uses critical thinking, research, and sound judgment to resolve ambiguous or non-routine reimbursement matters.

• Cross-Functional Influence — Coordinates effectively with Revenue Integrity, Legal, Compliance, payer relations, operational leaders, and executive stakeholders.

Essential Duties & Responsibilities

Complex Recovery Resolution

• Investigate and resolve high-dollar reimbursement discrepancies, complex denials, underpayments, and payment variances.

• Manage escalated payer disputes that require advanced research, documentation, negotiation, or cross-functional intervention.

• Develop and execute recovery strategies for financially significant claims and reimbursement matters.

• Interpret payer contractual obligations, fee schedules, reimbursement methodologies, and applicable payment terms.

• Maintain clear documentation of investigation findings, actions taken, payer responses, and resolution outcomes.

Advanced Appeals & Government Reimbursement

• Develop and support advanced payer appeals and escalation packages using claim history, documentation, contractual terms, and reimbursement requirements.

• Manage Medicare redetermination and reconsideration activities and support Administrative Law Judge (ALJ) matters as applicable.

• Evaluate appeal viability, financial impact, filing requirements, deadlines, and supporting evidence before escalation.

• Track complex appeal and dispute outcomes and identify recurring payer behaviors or reimbursement risks.

• Escalate payer compliance or reimbursement concerns when standard recovery channels have been exhausted.

Financial Analysis & Revenue Protection

• Perform detailed claim, payment, remittance, contract, and reimbursement audits to identify discrepancies and recovery opportunities.

• Quantify reimbursement losses, underpayments, financial exposure, and potential recovery value.

• Develop financial impact assessments to support prioritization, escalation, and leadership decision-making.

• Identify systemic patterns contributing to high-dollar denials, underpayments, or reimbursement leakage.

• Recommend corrective actions or process improvements that reduce recurrence and protect future revenue.

Escalation Management & Cross-Functional Collaboration

• Serve as an advanced escalation resource for complex reimbursement questions and financially significant cases.

• Coordinate with Legal, Compliance, payer relations, Revenue Integrity, Billing, Order Management, Finance, and operational leaders when appropriate.

• Prepare clear case summaries, supporting analysis, and recommended resolution strategies for leadership or executive review.

• Partner with internal teams to obtain documentation, clarify operational facts, and resolve barriers affecting recovery.

• Share findings and lessons learned that improve team knowledge and future complex-case resolution.

Success in this role will be measured against the following Key Performance Indicators (KPIs) once performance benchmarks and baseline expectations have been established

• High-Dollar Recovery Value

• Escalation Resolution Rate

• Financial Exposure Mitigation

• Underpayment Recovery

Experience & Education

• Five (5)+ years of advanced healthcare reimbursement, denial management, appeals, underpayment, or revenue recovery experience.

• Demonstrated expertise interpreting payer contracts, fee schedules, reimbursement methodologies, remittance details, and payment variances.

• Experience resolving complex or high-dollar denials, underpayments, payer disputes, and escalated reimbursement matters.

• Working knowledge of Medicare redetermination, reconsideration, and Administrative Law Judge (ALJ) appeal processes preferred.

• Strong analytical and financial review capabilities with the ability to quantify reimbursement exposure and recovery opportunity.

• Ability to synthesize complex claim, payment, contract, and documentation information into clear findings and resolution strategies.

• Strong written and verbal communication skills with the ability to influence payer representatives and internal stakeholders.

• Exceptional critical-thinking, research, organization, and problem-solving skills with strong attention to detail.

• Experience with DME/HME reimbursement, payer portals, revenue cycle systems, reporting tools, and Microsoft Office preferred.