Job Summary
The Accounts Receivable (AR) Appeals Specialist is responsible for managing the end-to-end Accounts Receivable (AR) denial and appeals process to maximize insurance reimbursement and support revenue cycle performance. This role independently researches claim denials, analyzes denial codes and payer policies, prepares and submits first-level and subsequent appeals, follows up with insurance payers, and resolves reimbursement issues through final payment resolution. The specialist is expected to demonstrate strong expertise in AR follow-up, denial management, reimbursement recovery, payer guidelines, and healthcare revenue cycle operations while identifying opportunities to improve reimbursement outcomes and operational efficiency.
Screening Criteria
- Minimum of three (3) years of hands-on Accounts Receivable (AR) experience within the US healthcare revenue cycle.
- Proven experience independently managing denied or underpaid claims from initial review through final resolution.
- Experience preparing, submitting, and following up on first-level, second-level, and subsequent insurance appeals.
- Strong experience reviewing denial codes (e.g., CO50, CO96, CO16, CO197), determining corrective actions, and resolving reimbursement issues.
- Experience researching payer policies, reimbursement guidelines, medical necessity criteria, and coverage requirements.
- Experience communicating directly with insurance payers regarding appeals, claim reprocessing, reimbursement, and payment disputes.
- Stable employment history.
Job Description
- Manage denied, rejected, and underpaid healthcare claims throughout the full AR denial and appeals lifecycle.
- Review denial codes, payer responses, and reimbursement outcomes to determine the appropriate corrective action.
- Prepare, submit, and monitor first-level, second-level, reconsideration, and subsequent insurance appeals.
- Research payer policies, medical necessity guidelines, coverage criteria, and supporting documentation to strengthen appeal submissions.
- Contact insurance carriers to obtain claim status, request claim reprocessing, resolve payment discrepancies, and negotiate reimbursement issues.
- Analyze denial trends, reimbursement barriers, and payer performance to identify recurring issues and recommend process improvements.
- Manage coordination of benefits (COB), secondary insurance billing, and account transfers when applicable.
- Review Accounts Receivable aging reports and prioritize unresolved claims to maximize reimbursement recovery.
- Apply knowledge of ICD-10 coding, healthcare billing regulations, and payer-specific guidelines when resolving claim issues.
- Collaborate with billing, coding, operations, and other internal teams to resolve complex reimbursement challenges.
- Escalate claims through reconsiderations, second-level appeals, external reviews, or other appropriate channels when necessary.
- Maintain accurate documentation of appeal activities, payer communications, claim status, and reimbursement outcomes.
- Track key performance metrics related to denials, appeals, reimbursement recovery, and payer turnaround times.
- Support continuous process improvement initiatives that enhance revenue cycle efficiency and reduce future denials.
Required Qualifications
- Minimum of three (3) years of experience in US healthcare Accounts Receivable (AR), insurance follow-up, or denial management.
- Strong experience managing insurance claim denials, appeals, and reimbursement recovery from start to finish.
- Demonstrated knowledge of healthcare billing, Accounts Receivable workflows, revenue cycle management, and ICD-10 coding.
- Experience analyzing denial codes (e.g., CO50, CO96, CO16, CO197) and implementing appropriate corrective actions.
- Knowledge of payer contracts, reimbursement methodologies, medical necessity requirements, and insurance coverage guidelines.
- Experience handling reconsiderations, second-level appeals, external reviews, and payer escalations.
- Experience with Coordination of Benefits (COB) and secondary insurance billing is highly preferred.
- Proven ability to independently manage a high-volume workload while maintaining accuracy and meeting productivity goals.
- Excellent analytical, organizational, problem-solving, and documentation skills.
- Strong verbal and written English communication skills with experience interacting directly with insurance payers.
- Self-motivated, detail-oriented, adaptable, and able to thrive in a fast-paced healthcare revenue cycle environment.
