Denials and Appeals Specialist

Graham Regional Medical Center•Graham, TX

About The Position

The Denials & Appeals Specialist is responsible for managing, tracking, and resolving denials and appeals to ensure timely reimbursement. This role requires in-depth knowledge of payer guidelines, systems, and requirements to navigate complex denial cases effectively, assist in issue resolution, and help identify trends that can improve claim outcomes.

Requirements

Strong knowledge of payer guidelines, medical billing practices, and appeal processes
Proficiency in relevant software and claims management systems, such as Meditech, Quadax and Athena a plus
Excellent analytical skills for reviewing denial trends and suggesting improvements
Strong verbal and written communication skills to interact with payers and internal departments
Ability to prioritize tasks effectively and manage time in a fast-paced environment
Intermediate computer skills, including but not limited to: Microsoft Office, electronic medical record, and email
Strong command of / proficient in spoken and written English
Strong attention to detail
Ability to multi-task with multiple interruptions
Highschool diploma or GED required; Associate Degree or higher in Health Information Management preferred
3+ years of experience in Hospital billing, revenue cycle, or claims denials and appeals processing required.
Prior experience with revenue cycle processes in a hospital required.
Prolonged periods sitting at a desk and working on a computer
Must be able to lift up to 25 pounds at times
Must be able to navigate various departments of the organization’s physical premises
Sufficient hearing, vision, and dexterity to perform duties safely

Nice To Haves

Physician practice experience a plus

Responsibilities

Monitors assigned queues and duties across various systems, to ensure all follow-up dates are current.
Analyzes denials to determine appropriate actions, completes appeals, or routes cases for clinical appeals as needed.
Files and monitors appeals to resolve payer denials, documenting all activity accurately and maintaining logs, account notes, and system records.
Maintains an up-to-date understanding of payer guidelines and requirements related to denials and appeals.
Processes internal requests, reviews Government Audit accounts, Payer refund requests related to overpayments and completes necessary rebills and adjustments.
Identifies trends in denials to suggest improvements and reduce future claim issues, providing data for denial and appeal trends as needed.
Assist with, complete, and provide coding and billing documentation to ensure accurate coding and billing practices to maximize revenue and minimize claim denials.
Answer inquiries from patients.
Maintain compliance with relevant regulations, including HIPAA, and payer-specific guidelines
Perform other related duties to benefit the mission of the organization