Position Summary
The Denial Management Specialist is responsible for reviewing, analyzing, and resolving payer denials. The role focuses on root-cause identification, appeal submission, and prevention strategies to improve first-pass acceptance and revenue recovery.
Key Responsibilities
Denial Review & Resolution
- Analyze denial codes, EOBs, and payer correspondence.
- Determine corrective actions: corrected claim, appeal, or documentation request.
- Prepare appeal packets including clinical notes, letters, and supporting evidence.
Root-Cause Analysis
- Categorize denials (coding, eligibility, authorization, bundling, documentation).
- Identify trends and escalate repeat issues to team leadership.
Tracking & Reporting
- Maintain denial logs with actions, outcomes, and recovery amounts.
- Provide weekly denial summary reports and recommendations.
Cross-Functional Collaboration
- Work with coders, billers, and charge entry to correct workflows.
- Provide education on recurring denial patterns.
Qualifications
Required
- 2+ years in denial management or AR follow-up.
- Eye experience preferred
- Knowledge of payer policies, appeal timelines, and CARC/RARC codes.
- Strong analytical and written communication skills.
Preferred
- Experience with specialty care denials (especially retina).
- Familiarity with payer portals and electronic appeals.
- Familiarity with PM/EHR systems (e.g., Healthpac, NextTech, ModMed, ECW, Athena, MedInformatics, AdvancedMD).
Core Competencies
- Analytical problem-solving
- Written communication
- Documentation review
- Persistence and follow-through
- Organization
- Attention to detail
Work Environment
- Remote or hybrid based on company structure.
- May require occasional payer calls or joint review meetings.