Denials & Appeals Specialist

American Addiction Centers•Worcester, MA

About The Position

The Denials & Appeals Specialist investigates, resolves, and appeals denied insurance claims from third-party payers. The role analyzes unpaid and denied claims, identifies the reasons for denial, and applies resolution strategies to recover revenue and minimize organizational write-offs. It requires knowledge of medical coding, payer guidelines, and the healthcare revenue cycle. The specialist reviews claims and related records, researches payer policies and deadlines, prepares and submits appeals, corrects and resubmits claims, and follows up with insurers. The role also collaborates with coding, billing, and clinical teams; documents account activity; monitors accounts receivable; and assists with reporting on denial trends, appeal outcomes, and recovered revenue. AAC describes its culture as valuing work/life balance, education, trust, and respect, and its mission is to provide compassionate, innovative care to adults experiencing addiction and co-occurring mental health disorders.

Requirements

High school diploma or GED equivalent.
1–2 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, and familiarity with UB-04 and CMS-1500 claim formats.
Experience with healthcare revenue cycle platforms and insurance web portals.
Meticulous attention to detail when reviewing clinical documentation and insurance contracts.
Excellent written and verbal communication skills, particularly for drafting persuasive appeal letters.
Strong analytical problem-solving skills to troubleshoot claim histories and identify resolution pathways.
Ability to perform essential duties satisfactorily, with reasonable accommodations available for individuals with disabilities.
Ability to sit at a desk for prolonged periods and lift 15 pounds at a time.

Nice To Haves

Associate or bachelor’s degree in Healthcare Administration or a related field.
Certified Professional Coder (CPC) or Certified Revenue Cycle Representative (CRCR) certification.
Experience with platforms such as Epic, NextGen, or eClinicalWorks and portals such as Availity.

Responsibilities

Review and analyze insurance claim denials and rejections using electronic health records and Explanation of Benefits or Remittance Advice documents.
Identify denial reasons, including medical necessity, missing prior authorization, coding errors, coordination of benefits, or eligibility issues.
Research payer policies, guidelines, and deadlines to assess denial validity.
Prepare and submit formal, clinical, or administrative appeal letters with supporting documentation.
Correct and resubmit modified claims using appropriate modifiers, ICD-10, and CPT codes.
Contact insurance companies by telephone or provider portals to track appeals and expedite resolution.
Partner with medical coding, billing, and clinical teams to obtain documentation and clarify coding discrepancies.
Educate internal departments about recurring denial trends to help prevent future claim rejections.
Communicate professionally and promptly with insurance representatives, management, and internal teams.
Document actions, correspondence, and appeal statuses in patient account ledgers and billing systems.
Monitor accounts receivable aging reports and follow up within payer deadlines.
Assist in generating reports on denial trends, appeal success rates, and recovered revenue.