Denial Recovery Specialist

Position Summary

The Denial Recovery Specialist is responsible for reviewing, analyzing, and resolving denied professional billing claims to ensure accurate and timely reimbursement. This role focuses on identifying root causes of denials, initiating corrective actions, and collaborating with coding, billing, and payer representatives to maximize revenue recovery and reduce future denials.

The ideal candidate demonstrates strong, payer knowledge, and a deep understanding of physician billing guidelines, reimbursement methodologies and analytical skills.

Key Responsibilities

Denial Resolution & Appeals

Review denied professional claims to determine root cause and appropriate resolution.

Research payer policies, contracts, and billing guidelines to support appeals.

Prepare and submit timely, well-documented appeals and reconsiderations.

Follow up with payers to ensure proper adjudication and payment.

Track appeal outcomes and identify trends in overturn rates.

Accounts Receivable Management

Manage assigned A/R workqueues to ensure timely follow-up.

Prioritize high-dollar and aging claims to optimize cash flow.

Monitor denial aging and escalate unresolved issues appropriately.

Root Cause Analysis & Prevention

Identify trends in denials by payer, provider, specialty, CPT, or diagnosis and escalate to management.

Collaborate with coding and billing teams to address documentation or submission errors.

Provide feedback to front-end and coding teams to prevent recurring denials.

Assist in developing process improvements to improve clean claim rates.

Compliance & Accuracy

Ensure all billing and appeal activities comply with CMS, Medicare, Medicaid, and commercial payer regulations.

Maintain accurate documentation of actions taken on accounts.

Protect patient confidentiality in accordance with HIPAA guidelines.

Reporting & Performance Monitoring

Track and maintain users own productivity and quality metrics.

Participate in team meetings and training initiatives.

Qualifications

Education

High school diploma required

Associate or Bachelor’s degree in Healthcare Administration, Business, or related field preferred

Experience

3–5 years of professional medical billing or denial management experience

Strong knowledge of CPT, ICD-10, HCPCS billing or coding fundamentals

Experience working with Medicare, Medicaid, and commercial payers

Familiarity with Epic EHR system

Clinical, CPC or RN background experience preferred

Core Competencies

Analytical and problem-solving skills

Knowledge of payer guidelines and reimbursement methodologies

Detail-oriented with strong documentation skills

Effective written and verbal communication

Ability to manage productivity goals and meet deadlines

Team-oriented with a proactive approach