Denial Resolution Specialist

Western Missouri Medical Center•Warrensburg, MO

About The Position

The Denial Resolution Specialist reviews and resolves denied claims to maximize reimbursement, reduce revenue leakage, and prevent future denials. The role works in MEDITECH denial work queues and serves as a subject matter expert on payer rules, denial trends, and appeals processes. It contributes to the organization’s financial health by recovering revenue and improving revenue cycle performance through root-cause identification and reduced rework. The specialist works assigned denial queues, analyzes EOBs/ERAs and payer codes, corrects and resubmits claims, submits reconsiderations and appeals, requests supporting documentation, and follows cases through resolution. The role also communicates with insurers, maintains accurate account documentation, and ensures compliance with CMS guidelines, payer contracts and requirements, and organizational policies. Denials are generally expected to be worked within a five-day target. The position requires current residency in Kansas or Missouri.

Requirements

High school diploma or equivalent required.
Current residency in Kansas or Missouri required.
At least 3 years of healthcare billing or revenue cycle experience.
Experience working in an EHR system; MEDITECH experience preferred.
Strong understanding of insurance billing and the claims lifecycle, EOB/ERA interpretation, payer rules, and denial codes.
Prior experience in denial management or appeals.
Analytical and critical-thinking skills, attention to detail, problem-solving ability, and root-cause identification skills.
Effective communication and negotiation skills.
Ability to manage high volumes and deadlines.
Ability to sit and stand intermittently for 8 to 10 hours a day.
Ability to use standard office equipment, including a telephone and computer keyboard.
Ability to work under pressure while maintaining near-100% accuracy and meeting inflexible deadlines.
Manual and bi-manual dexterity, near vision, speech, and hearing; eye/hand coordination and color definition.
Ability to reach above shoulder occasionally, lift and/or carry up to 40 pounds regularly, and walk on uneven surfaces occasionally.

Nice To Haves

Bachelor’s degree preferred.
Experience working in a clearinghouse; SSI preferred.
MEDITECH experience preferred.

Responsibilities

Review denied claims in MEDITECH denial work queues, including DEN-ELIG-, DEN-AUTH-, DEN-CODING-, DEN-MEDNEC-, and DEN-TIMELY-.
Analyze Explanation of Benefits (EOB) and Electronic Remittance Advice (ERA) information and payer codes (CARC/RARC).
Correct and resubmit claims, submit reconsiderations or formal appeals, and request additional documentation as appropriate.
Work denials within established service-level expectations, typically within five days.
Prepare and submit first-level and second-level appeals; gather and review medical records, coding documentation, and authorization details.
Track appeal status, follow through to resolution, and escalate complex or high-dollar cases as needed.
Work assigned accounts daily, meet productivity targets, and prevent work-queue backlog accumulation.
Prioritize high-dollar claims, timely filing deadlines, and aging denials.
Contact insurance companies to clarify denial reasons, request reconsideration, and verify appeal requirements.
Maintain knowledge of payer-specific policies and updates.
Accurately document actions taken on accounts and ensure compliance with CMS guidelines, payer contracts and requirements, and organizational policies.
Maintain regular and predictable attendance and perform other essential duties as assigned.