Job Description

The role serves as a liaison between Billing, payers, TPAs, adjusters, payer representatives, and internal teams to resolve reimbursement barriers and maximize appropriate payment. It includes managing aging receivables, reviewing AR reports, identifying recovery opportunities, and determining actions based on contracts, authorization requirements, payer rules, and billing guidelines.

This role requires strong knowledge of Workers’ Compensation billing, payer requirements, authorizations, appeals, contracts, fee schedules, claims processing, reimbursement, and revenue cycle management, with the ability to analyze balances, identify recovery opportunities, and drive claims toward resolution.

Critical Competencies

• Workers’ Compensation & Reimbursement Knowledge: Strong understanding of Workers’ Compensation processes, payer requirements, DME authorization, medical documentation, fee schedules, contracts, claims processes, injury claim lifecycle, and reimbursement requirements.

• Denials & Appeals Expertise: Demonstrated ability to evaluate denial rationale, determine whether a denial is appropriate, and apply effective appeal, reconsideration, correction, or other recovery strategies.

• AR & Revenue Recovery: Strong understanding of AR management, aging, payment resolution, underpayments, and revenue recovery strategies, with the ability to prioritize accounts based on financial impact, age, and likelihood of recovery.

• Analytical & Problem-Solving Skills: Ability to analyze complex claims, denial trends, payer behavior, payment patterns, and process issues to identify root causes, recovery opportunities, and solutions. Immediately reports payment and claims processing disruption to leadership.

• Payer Communication & Negotiation: Strong communication and negotiation skills with the ability to effectively work with carriers, TPAs, adjusters, and payer representatives to advocate for appropriate reimbursement and resolve complex issues.

• Case & File Review: Ability to review claims and supporting documentation across the patient’s file to identify authorization, documentation, billing, coverage, or other issues that may affect reimbursement.

• Judgment & Decision-Making: Ability to assess claim circumstances, payer requirements, financial impact, and available options to determine the most appropriate course of action and when escalation is necessary.

• Organization & Follow-Through: Strong attention to detail and ability to manage multiple claims, priorities, deadlines, payer follow-ups, appeals, and resolution activities while maintaining accurate documentation. Uses information on claims processing to support effective prevention strategies.

Essential Duties & Responsibilities

Payer & Stakeholder Relationship Management

• Develop and maintain professional relationships with insurance carriers, TPAs, adjusters, nurse case managers, and payer representatives.

• Serve as a primary point of contact for assigned reimbursement issues and recovery efforts.

• Advocate for appropriate claim adjudication and reimbursement.

• Collaborate with internal departments to obtain documentation and support claim resolution.

• Facilitate productive communication between external payers and internal operational teams.

• Support payer issue escalation and reimbursement resolution initiatives

Revenue Recovery & Resolution

• Manage complex Workers’ Compensation denials, underpayments, and outstanding accounts receivable.

• Investigate reimbursement barriers and determine the appropriate resolution strategy.

• Identify opportunities to recover revenue through appeals, reconsiderations, corrected claims, payment reviews, or payer escalation.

• Monitor and manage assigned accounts through final disposition and resolution.

• Prioritize recovery activities based on aging, financial impact, payer responsiveness, and likelihood of recovery.

• Support the achievement of departmental reimbursement and recovery objectives.

Denials Management & Appeals

• Review denied claims to identify denial rationale and root cause.

• Evaluate claim history, authorizations, clinical documentation, billing records, payer requirements, contracts, and fee schedules.

• Determine whether claims require appeal, reconsideration, correction, escalation, or other recovery actions.

• Prepare and submit appeals, reconsiderations, supporting documentation, and corrected claims.

• Monitor appeal status and follow through to resolution.

• Maintain complete documentation of denial activity, payer responses, and outcomes.

• Escalate high-risk, high-dollar, or recurring denial trends requiring leadership intervention.

• Identify opportunities to prevent future denials and improve reimbursement performance.

• Maintain detailed documentation of denial activity, actions taken, payer responses, and final outcomes.

• Identify recurring denial trends and communicate opportunities to improve processes and prevent future denials.

Accounts Receivable Management

• Review aging reports and prioritize outstanding balances requiring action.

• Investigate unpaid and underpaid claims to determine causes of delayed reimbursement.

• Conduct proactive follow-up with carriers, TPAs, adjusters, and payer representatives.

• Track payer commitments, requested actions, and follow-up activities.

• Coordinate internal resources required to resolve reimbursement barriers.

• Escalate unresolved balances when standard collection efforts have been exhausted.

• Maintain accurate records of collection activities, payer correspondence, and recovery outcomes.

SME Support & Knowledge Leadership

• Serve as the departmental subject matter expert for Workers’ Compensation of reimbursement and recovery activities.

• Provide guidance regarding payer requirements, reimbursement methodologies, fee schedules, and authorization requirements.

• Assist with complex claim reviews, escalations, and recovery strategy development.

• Support training and knowledge-sharing initiatives across operational teams.

• Participate in payer discussions and reimbursement-related projects as assigned.

• Assist leadership in the development of policies, procedures, workflows, and best practices related to Workers’ Compensation recovery and resolution activities.

Documentation & Reporting

• Maintain accurate and timely documentation within billing systems and company platforms.

• Document payer communications, recovery efforts, claim reviews, appeals, escalations, and resolutions.

• Maintain reporting related to denial activity, collections of performance, aging accounts, reimbursement trends, and recovery outcomes.

• Prepare reports and analysis for departmental and leadership review.

• Support audit readiness and compliance requirements through accurate recordkeeping.

Key Performance Indicators

• Revenue Recovery Performance: Total dollars recovered from denied, underpaid, and aging Workers’ Compensation claims.

• Denial Resolution Effectiveness: Denial resolution rate and appeal success rate.

• Accounts Receivable Management: Reduction of AR over 90 days and timely resolution of assigned accounts.

• Payer Resolution & Escalation: Successful resolution of complex payer issues, underpayments, and reimbursement disputes.

• Trend Identification & Prevention: Identification of denial trends, root causes, and opportunities to prevent future revenue leakage.

• Productivity & Follow-Through: Completion of assigned recovery activities, payer follow-up, and escalation management within established timeframes.

• Documentation & Compliance: Accuracy, completeness, and timeliness of claim documentation, appeals, payer communications, and recovery records.

• Collaboration & SME Support: Effective partnership with operational teams and contribution to reimbursement education, process improvement, and recovery initiatives.

Minimum Qualifications Required

• High school diploma or equivalent required; associate degree or relevant healthcare coursework preferred.

• Minimum three (3) years of experience in Workers’ Compensation reimbursement, denial management, appeals, accounts receivable, healthcare reimbursement, revenue cycle operations, or related healthcare functions.

• Experience working directly with insurance carriers, TPAs, adjusters, nurse case managers, and payer representatives.

• Working knowledge of reimbursement methodologies, authorization requirements, medical documentation, and healthcare billing processes.

• Strong analytical, communication, negotiation, organization, and problem-solving skills.

• Proficiency with Microsoft Office and healthcare billing platforms.

• Ability to manage multiple complex reimbursement issues simultaneously while maintaining accuracy and professionalism.

Preferred

• Bachelor's degree in healthcare administration, Business Administration, Nursing, Finance, Communications, or related fields.

• DME/HME reimbursement experience.

• Advanced experience with denial analytics, reimbursement recovery, payer escalations, and revenue cycle optimization.

• Experience supporting operational improvement initiatives and reimbursement strategy development