Revenue Appeals & Denials Specialist

OrthoArkansas•North Little Rock, AR

About The Position

The Revenue Appeals and Denials Specialist at OrthoArkansas plays a critical role in protecting and maximizing reimbursement by resolving denied, underpaid, and outstanding insurance claims. This position is responsible for investigating claim denials, preparing appeals, recovering lost revenue, and identifying reimbursement trends that impact organizational performance. The ideal candidate possesses strong analytical skills, a thorough understanding of insurance reimbursement methodologies, and experience navigating complex payer requirements. This individual will work collaboratively with providers, coders, financial counselors, and leadership to ensure timely and accurate claim resolution while supporting the overall financial health of the organization.

Requirements

High school diploma or GED required.
Minimum of two (2) years of experience in medical billing, insurance follow-up, denial management, accounts receivable, or revenue cycle operations.
Experience working insurance denials, appeals, medical necessity denials, authorization denials, and payer-specific reimbursement issues.
Experience interpreting EOBs, ERAs, payer policies, and reimbursement guidelines.
Strong understanding of medical billing, insurance reimbursement, and denial management.
Knowledge of Medicare, Medicaid, Workers' Compensation, and commercial insurance plans.
Excellent analytical and problem-solving abilities.
Strong written communication skills with the ability to prepare professional appeal letters.
Exceptional attention to detail and organizational skills.
Ability to prioritize and manage multiple deadlines in a fast-paced environment.
Strong interpersonal and customer service skills.
Commitment to patient confidentiality and HIPAA compliance.
Advanced: Alphanumeric Data Entry.
Intermediate: Practice Management Systems, Database Management, Spreadsheet Applications, Word Processing, 10-Key Data Entry.
Basic: Accounting Software, Contact Management Systems.

Nice To Haves

Orthopedic billing experience preferred.
Associate degree or equivalent healthcare revenue cycle experience preferred.
Experience with payer contract analysis and reimbursement recovery preferred.
Knowledge of CPT, HCPCS, and ICD-10 coding concepts preferred.
Experience identifying denial trends and implementing corrective actions preferred.
Familiarity with payer portals and online claim management systems preferred.
Experience creating reports and analyzing reimbursement data preferred.
Mentoring or training experience preferred.

Responsibilities

Manage payer-specific denial and accounts receivable work queues, processing approximately 70 claims daily.
Investigate unpaid, denied, and underpaid claims to secure appropriate reimbursement.
Research denial reasons and determine the appropriate corrective action.
Identify and resolve claim issues related to coding, authorizations, eligibility, medical necessity, bundling edits, and payer-specific requirements.
Work escalated, high-dollar, and aged accounts requiring advanced review and resolution.
Review Explanation of Benefits (EOBs), Electronic Remittance Advice (ERAs), payer policies, and reimbursement guidelines.
Prepare and submit first-level, second-level, and complex appeal letters with supporting documentation.
Monitor appeal deadlines and ensure timely submission of all required materials.
Communicate with insurance carriers regarding appeal status and claim reconsiderations.
Partner with providers and coding staff to obtain documentation necessary to support appeals.
Track appeal outcomes and identify opportunities to improve reimbursement success rates.
Identify opportunities for additional reimbursement and revenue recovery.
Review payer contracts and reimbursement methodologies when investigating payment discrepancies.
Research payer policies and coverage determinations to support claim resolution efforts.
Analyze denial trends and recommend corrective actions to prevent future denials.
Assist leadership in identifying root causes of reimbursement challenges and developing solutions.
Maintain detailed and accurate account documentation within the practice management system.
Respond to inquiries regarding claim status, denials, appeals, and reimbursement activity.
Communicate professionally with insurance carriers, providers, and internal departments.
Provide updates on complex accounts and reimbursement issues to management.
Partner with coding, registration, authorization, and clinical teams to resolve claim issues and improve workflows.
Participate in meetings regarding payer updates, reimbursement changes, and denial trends.
Assist with training and mentoring team members regarding denial management and appeal strategies.
Contribute to process improvement initiatives aimed at reducing denials and increasing reimbursement efficiency.
Perform other related duties as assigned to support revenue cycle operations.