Denials & Appeals Specialist

American Addiction Centers•Worcester, MA

4h•$26 - $35•Onsite

About The Position

The Denials & Appeals Specialist is responsible for investigating, resolving, and appealing denied insurance claims from third-party payers. This role focuses on analyzing unpaid and denied claims, identifying the root cause of the denial, and executing effective resolution strategies to recover revenue and minimize organizational write-offs. The ideal candidate possesses a deep understanding of medical coding, payer guidelines, and the health insurance revenue cycle.

Requirements

High School Diploma or GED equivalent required
2–4 years of experience in healthcare billing, medical collections, or accounts receivable, with a dedicated focus on insurance denial management.
Strong proficiency in ICD-10-CM, CPT, and HCPCS coding, as well as UB-04 and CMS-1500 claim formats.
Experience with major healthcare revenue cycle platforms (e.g., Epic, NextGen, eClinicalWorks) and insurance web portals (e.g., Availity).
Meticulous approach to reviewing complex clinical documentation and legal insurance contracts.
Excellent written and verbal communication skills, specifically for drafting persuasive appeal letters.
Strong analytical skills to troubleshoot complex claim histories and find creative resolution pathways.

Nice To Haves

Associates or Bachelor’s degree in Healthcare Administration or related field preferred.
Certified Professional Coder (CPC) or Certified Revenue Cycle Representative (CRCR) is highly preferred but not always required.

Responsibilities

Review and analyze insurance claim denials and rejections utilizing Electronic Health Records (EHR) and Explanation of Benefits (EOB) / Remittance Advices (RA).
Identify the specific reason for denial (e.g., medical necessity, missing prior authorization, coding errors, coordination of benefits, or eligibility issues).
Research payer-specific policies, guidelines, and deadlines to determine the validity of the denial.
Prepare and submit formal, clinical, or administrative appeal letters with necessary supporting documentation (medical records, doctor's notes, proof of timely filing).
Correct and re-submit modified claims using appropriate modifiers, ICD-10, and CPT codes.
Routinely contact insurance companies via telephone or provider portals to track the status of appeals and expedite resolution.
Partner with Medical Coding, Billing, and Clinical teams to obtain missing documentation or clarify coding discrepancies.
Educate internal departments on recurring denial trends to prevent future claim rejections.
Maintain professional and timely communication with insurance representatives, management, and internal teams.
Accurately document all actions taken, correspondence received, and appeal statuses in the patient account ledger and billing system.
Monitor accounts receivable (A/R) aging reports to ensure timely follow-up within strict payer-imposed deadlines.
Assist in generating reports on denial trends, appeal success rates, and recovered revenue.