Position Summary

The Insurance Denial Specialist is responsible for reviewing, analyzing, and resolving denied or underpaid insurance claims to ensure accurate and timely reimbursement for hospital and professional services. This position works closely with billing staff, clinical departments, physicians, and insurance payers to identify denial trends, correct claim issues, submit appeals, and improve overall revenue cycle performance.

The ideal candidate demonstrates strong analytical skills, knowledge of healthcare insurance processes, payer regulations, medical terminology, and hospital billing practices.

Essential Duties and Responsibilities

Review and resolve denied, rejected, and underpaid claims from commercial, government, and managed care payers.
Investigate denial reasons and determine appropriate corrective action.
Prepare and submit timely appeals with supporting documentation.
Work closely with coding, billing, case management, utilization review, and clinical departments to obtain necessary information for appeals and claim corrections.
Monitor payer portals and insurance correspondence for claim status updates.
Identify recurring denial trends and communicate findings to leadership.
Ensure compliance with payer guidelines, CMS regulations, and hospital policies.
Maintain productivity and accuracy standards established by the department.
Follow up on outstanding accounts receivable related to denials and appeals.
Document all actions taken within the billing and patient accounting systems.
Assist with payer audits and requests for additional information.
Participate in process improvement initiatives to reduce future denials and improve reimbursement.
Maintain confidentiality of patient information in accordance with HIPAA regulations.
Perform other duties as assigned.

Minimum Qualifications

Education

High school diploma or equivalent required.
Associate degree in Healthcare Administration, Medical Billing & Coding, or related field preferred.

Experience

Minimum of two (2) years of healthcare billing, insurance follow-up, denial management, or revenue cycle experience preferred.
Hospital acute care billing experience preferred.

Knowledge, Skills, and Abilities

Knowledge of medical terminology, CPT, ICD-10, and HCPCS coding concepts.
Understanding of commercial insurance, Medicare, Medi-Cal, and managed care reimbursement methodologies.
Familiarity with claim appeals and denial resolution processes.
Strong analytical and problem-solving skills.
Ability to prioritize workload and meet deadlines.
Excellent written and verbal communication skills.
Proficient computer skills, including EMR and billing systems.
Ability to work independently and collaboratively in a fast-paced environment.

Preferred Qualifications

Certified Professional Biller (CPB) or related certification preferred.
Experience with hospital information systems and revenue cycle platforms.
Prior experience with payer audits and appeals management.

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