Claims Denial and Appeals Specialist

Orthopaedic Associates of Michigan•Grand Rapids, MI

18h•Onsite

About The Position

The Claims Denial and Appeals Specialist reviews, analyzes, and resolves denied or underpaid insurance claims to support accurate and timely reimbursement. The role manages accounts receivable by investigating denials, preparing appeals, monitoring payer reimbursement activity, and identifying denial trends. It works directly with insurance carriers, patients, and internal departments to support revenue cycle integrity and improve reimbursement outcomes. The specialist also assists with financial counseling, payer communications, and account reconciliation while maintaining compliance with HIPAA and organizational policies. This onsite, full-time position is based at 555 MidTowne NE, Grand Rapids, MI 49503. The workweek is 40 hours, Monday through Friday, with office hours from 7:00 AM to 5:00 PM. Employees may choose a consistent daily start time between 7:00 and 8:30 AM. The position has no direct reports.

Requirements

High school diploma, GED, or equivalent.
At least one year of experience in medical billing, insurance appeals, accounts receivable, revenue cycle, or a related healthcare business office function.
Knowledge of third-party payer reimbursement methodologies and insurance claim processing.
Knowledge of CPT, ICD-10-CM, HCPCS, and applicable modifiers.
Working knowledge of HIPAA regulations and confidentiality requirements.
Excellent written and verbal communication skills.
Strong customer service and patient relations skills.
Proficiency in Microsoft Office applications.
Strong analytical and problem-solving abilities.
Ability to independently manage multiple priorities and deadlines.
Strong organizational and time management skills.
Effective interpersonal skills and ability to collaborate across departments.
Ability to maintain professionalism and confidentiality when handling sensitive information.
Ability to interpret payer guidelines, contracts, and reimbursement policies.
Ability to adapt to changing priorities in a fast-paced healthcare environment.
Ability to sit and/or stand for prolonged periods.
Manual dexterity to operate modern office equipment.
Ability to frequently handle files, records, and medical charts.
Frequent bending, reaching, and light lifting; ability to lift up to 20 pounds.
Normal or correctable range of hearing and eyesight.
An equivalent combination of education and experience may be considered.

Nice To Haves

One to two years of college coursework, vocational training, or equivalent healthcare revenue cycle education.
Experience with computerized patient accounting systems.
Experience with electronic remittance processing and payer portal management.
Previous experience in an ambulatory surgery center, orthopedic practice, or healthcare setting.

Responsibilities

Review and analyze denied insurance claims to determine appropriate appeal and reimbursement actions.
Research denial reasons and prepare supporting documentation for claim appeals.
Communicate with insurance payers about denied, underpaid, or inaccurately processed claims.
Resubmit denied or corrected claims to ensure appropriate reimbursement.
Audit patient accounts to verify payments, balances, contractual adjustments, coding accuracy, and claim status.
Monitor reimbursement activity and notify leadership of payment variances or discrepancies.
Identify, document, and communicate denial trends and recurring reimbursement issues.
Recommend process improvements and system enhancements to reduce future claim denials.
Collaborate with payers to understand denial causes and implement preventative measures.
Process insurance refunds accurately and promptly after receiving payments and explanations of benefits.
Review aged accounts receivable reports and pursue outstanding patient and insurance balances.
Coordinate daily and monthly accounts receivable reconciliation activities with the Business Office Manager.
Provide financial counseling to patients and assist with approved payment arrangements.
Access and maintain payer websites to obtain authorization, eligibility, and claim status information.
Protect confidential payer portal credentials and sensitive information.
Maintain accurate and current patient account documentation.
Respond professionally and promptly to patient and insurance inquiries.
Assist with departmental coverage and support team members as operational needs require.
Participate in cross-training within Business Office functions, including insurance verification and medical records.
Meet management-established productivity, quality, and timeliness standards.
Perform other duties as assigned.