Job Description

Working with a high degree of analytical judgment, attention to detail, and written communication, the Specialist tracks payer responses and appeal outcomes, conducts denial root cause analysis, escalates payer compliance concerns, and partners with operational teams to address recurring issues. The role is both recovery-focused and preventive: successful performance includes recovering dollars already at risk while identifying opportunities to reduce future denial recurrence.

Core Competencies

• Appeals Development — Builds clear, evidence-based payer appeals that address denial rationale and support reimbursement recovery.

• Revenue Recovery — Prioritizes and resolves denied and underpaid claims to maximize appropriate reimbursement and preserve revenue.

• Denial Analysis — Investigates denial patterns, payer responses, and root causes to identify corrective and preventive opportunities.

• Payer Reimbursement Knowledge — Applies knowledge of payer reimbursement methodologies, requirements, and claim-resolution practices.

• Analytical Thinking — Evaluates claim history, payment outcomes, supporting documentation, and payer behavior to determine the appropriate recovery strategy.

• Written Communication — Produces concise, persuasive, and well-supported appeal correspondence and escalation documentation.

• Cross-Functional Collaboration — Partners with operational departments to resolve claim issues and reduce recurring denial drivers.

• Revenue Protection — Balances timely recovery activity with prevention efforts that strengthen long-term reimbursement performance.

Essential Duties & Responsibilities

Denial Resolution & Appeals

• Review denied claims to determine denial rationale, financial impact, and appropriate recovery action.

• Develop and submit payer appeals supported by claim history, documentation, reimbursement requirements, and applicable payer guidance.

• Track appeal status, outcomes, payer responsiveness, and required follow-up through final resolution.

• Escalate complex, recurring, or payer-compliance concerns to leadership as appropriate.

Underpayment & Revenue Recovery

• Review incorrectly paid and underpaid claims and identify opportunities for additional reimbursement.

• Pursue recovery activity in accordance with payer requirements and internal revenue cycle processes.

• Prioritize recovery work based on financial impact, aging, appeal deadlines, and likelihood of successful resolution.

• Maintain accurate documentation of recovery actions, payer responses, and final outcomes.

Denial Strategy & Root Cause Analysis

• Conduct denial root cause analysis to identify recurring payer, documentation, workflow, or submission issues.

• Analyze denial and appeal outcomes to identify trends and opportunities to improve recovery performance.

• Recommend corrective or preventive actions that may reduce future denial recurrence and avoidable revenue loss.

• Share relevant denial themes and payer insights with leadership and operational partners.

Operational Collaboration

• Collaborate with Order Management, Billing, Revenue Operations, Patient Experience, Clinical teams, and other operational partners as needed to resolve denial drivers.

• Coordinate with appropriate teams to obtain documentation or information required to support appeals and recovery.

• Support cross-functional investigations and process improvements related to denial prevention, reimbursement recovery, and payer performance.

Success will be measured against the following Key Performance Indicators (KPIs) once performance benchmarks and baseline expansions have been established.

• Appeals Success Rate

• Denial Overturn Rate

• Recovery Dollars

• Underpayment Recovery

• Revenue Preservation

Experience & Education

• High school diploma or equivalent required; additional education in healthcare administration, business, billing, coding, or a related field preferred.

• Two (2) to three (3)+ years of denial management, appeals, reimbursement recovery, healthcare billing, or related revenue cycle experience.

• Working knowledge of payer reimbursement methodologies, claim adjudication, denial reasons, appeal processes, and recovery practices.

• Healthcare revenue cycle experience with demonstrated ability to investigate and resolve complex reimbursement issues.

• Strong analytical and critical-thinking skills with the ability to interpret claim history, payer responses, payment information, and supporting documentation.

• Excellent written communication skills with the ability to develop clear, persuasive, and well-supported appeals.

• Strong organizational skills, attention to detail, and ability to manage multiple claims, deadlines, and follow-up requirements.

• Commercial payer denial and appeals experience preferred.

• DME/HME reimbursement, underpayment recovery, or payer escalation experience preferred.

• Healthcare reimbursement, billing, coding, or revenue cycle certification preferred.