Denials & Appeals Specialist

American Addiction Centers•Worcester, MA

2d•$26 - $35

About The Position

The Denials & Appeals Specialist investigates, resolves, and appeals insurance claim denials from third-party payers. The role analyzes unpaid and denied claims, identifies root causes, and carries out resolution strategies to recover revenue and minimize organizational write-offs. It requires knowledge of medical coding, payer guidelines, and the health insurance revenue cycle. The specialist reviews denials and rejections in electronic health records and explanation-of-benefits or remittance documents; researches payer policies and deadlines; prepares and submits appeals with supporting documentation; 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 aging, and assists with reporting on denial trends, appeal outcomes, and recovered revenue.

Requirements

High school diploma or GED equivalent required.
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 UB-04 and CMS-1500 claim formats.
Experience with healthcare revenue cycle platforms such as Epic, NextGen, or eClinicalWorks and insurance web portals such as Availity.
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 and problem-solving skills to troubleshoot complex claim histories and identify resolution pathways.

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.

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-specific 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 missing documentation or 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-imposed deadlines.
Assist in generating reports on denial trends, appeal success rates, and recovered revenue.