Under the direct supervision of the Director of Operations, the Denial Specialist is responsible for reviewing, researching, and resolving line-item claim denials for Medicaid and commercial insurance payers.

This role focuses on identifying the root cause of denials, preparing and submitting appeals, and ensuring timely reimbursement by following payer-specific guidelines and regulatory requirements. The Denial Specialist works collaboratively with billing, coding, and clinical teams to maximize reimbursement while maintaining compliance with federal, state, and payer regulations.

Key responsibilities include:

Review and analyze line-item denials from Medicaid and commercial insurance carriers.
Investigate denied claims to determine the reason for denial and identify appropriate corrective action.
Prepare, submit, and track first-level and subsequent appeals within payer filing deadlines.
Interpret payer policies, contracts, medical necessity guidelines, and reimbursement requirements.
Collaborate with billing, coding, credentialing, and clinical staff to obtain supporting documentation for appeals.
Correct claim errors, coding discrepancies, modifiers, authorization issues, and documentation deficiencies when appropriate.
Monitor appeal status and follow up with insurance companies until final resolution.
Maintain detailed documentation of denial research, appeal activity, and claim outcomes in the billing system.
Identify denial trends and recurring issues and communicate findings to leadership.
Ensure compliance with HIPAA, CMS, Medicaid regulations, and commercial payer requirements.
Meet productivity and quality standards for denial resolution and accounts receivable management.
Assist with special projects and other revenue cycle duties as assigned.

Denials Specialist