Appeals & Denial Specialist

Description

Position Overview

We are seeking an experienced Appeals Specialist to join our growing healthcare organization. This role is responsible for managing insurance denials and payer disputes from identification through resolution, ensuring accurate reimbursement for services rendered.

The ideal candidate has a strong background in orthopedic and/or interventional pain management billing, understands complex procedural coding, and is comfortable navigating payer policies, medical necessity requirements, and appeal escalations.

This position plays a critical role in protecting revenue integrity while supporting efficient patient care operations.

Key Responsibilities

• Review, analyze, and resolve insurance claim denials and underpayments
   
• Prepare and submit first-level and escalated appeals to commercial and government payers
   
• Interpret EOBs, payer correspondence, and denial codes to determine root cause
   
• Draft detailed appeal letters supported by clinical documentation and payer guidelines
   
• Collaborate with billing, coding, clinical staff, and leadership to obtain necessary records
   
• Track appeal status and maintain accurate documentation within billing systems
   
• Monitor payer trends and identify recurring denial patterns
   
• Recommend workflow or documentation improvements to reduce future denials
   
• Maintain productivity and turnaround time standards

Requirements

Required Qualifications

• Minimum 2 years of appeals or denial management experience in a medical billing or revenue cycle environment
   
• Strong knowledge of insurance claims lifecycle and reimbursement processes
   
• Experience working with commercial, Medicare, and workers’ compensation payers
   
• Ability to interpret medical records and clinical documentation
   
• High attention to detail with strong organizational skills
   
• Proficiency with EMR and practice management systems
   
• Excellent written and verbal communication skills
   

Preferred Qualifications

• 2+ years of orthopedic or pain management billing/appeals experience strongly preferred
   
• Experience with interventional procedures, surgery center billing, or specialty practices
   
• Understanding of CPT, ICD-10, and modifier usage related to procedural specialties
   
• Familiarity with medical necessity appeals and authorization denials
   
• Certification such as CPC, CPB, or CRCR (preferred but not required)