Billing Denials Specialist

Qualifications

· Education

· Licensure

· Work Experience

· Skills/computer/ specific technical

§ Other qualifications, miscellaneous

Specify if qualifications are Required or Preferred

• Associate's or Bachelor's degree in Health Information Management, Healthcare Administration, Nursing, or a related field preferred; equivalent work experience considered.

• Minimum of 2-4 years of experience in medical billing, claims denial management, appeals, utilization review, or revenue cycle operations.

• Working knowledge of ICD-10, CPT, and HCPCS coding, medical terminology, and payer reimbursement methodologies.

• Familiarity with Medicare, Medicaid, and commercial payer denial and appeal guidelines.

• Certified Coding Specialist (CCS), Certified Professional Coder (CPC), or Certified Revenue Cycle Representative (CRCR) credential a plus.

• Proficiency with electronic health record (EHR) and practice management/billing systems.

• Strong written and verbal communication skills, with the ability to construct clear, evidence-based appeal letters.

Essential Job Responsibilities

Achieving Results

Key Components: assess, plan, evaluate, demonstrate initiative, quality of work, productivity

· Meets or exceeds established productivity and turnaround-time targets for denial resolution and appeal submission.

· Successfully overturns a measurable percentage of denied claims through accurate, well-documented appeals.

· Prioritizes workload effectively to meet payer-specific filing deadlines and avoid timely-filing losses.

· Tracks outcomes and follows through until each denial is resolved, escalated, or closed appropriately.

Demonstrates Skill

Key Components: competency, job knowledge, organizational skills, analytical skill, management of information, employee & patient safety

Technical Expertise

• Expert-level understanding of denial types (clinical necessity, coding, authorization, timely filing, COB) and corresponding appeal strategies.

• Strong command of payer contracts, fee schedules, and reimbursement logic across Medicare, Medicaid, and commercial lines of business.

• Proficiency in hospital billing and revenue cycle systems (Epic) and payer web portals.

• Familiarity with denial management and workflow automation platforms (e.g., Kodiak, Optum360, Availity).

• Working knowledge of clinical documentation requirements, ICD-10-CM/PCS coding principles, and clinical criteria sets (InterQual, Milliman).

Planning & Coordinating

Key Components: delegates, decision making, problem solving, management of resources

· Organizes and manages a high-volume caseload of denials and appeals to ensure timely, orderly processing.

· Coordinates with coding, clinical documentation, case management, and billing teams to gather supporting documentation.

· Maintains an organized tracking log or dashboard of denial status, appeal deadlines, and outcomes.

· Schedules and leads regular denial-trend review meetings with relevant stakeholders.

Professionalism

Key Components: dependability, interpersonal skills, teamwork, patient first ethic, customer service, communication skills, punctuality/attendance, receptiveness to criticism, judgment, confidentiality

• Maintains confidentiality of patient information in accordance with HIPAA and organizational policy.

• Communicates respectfully and collaboratively with payers, providers, and internal departments.

• Represents the organization professionally in all written and verbal payer interactions.

• Exercises sound judgment and integrity when handling sensitive financial and clinical information.