We are seeking a highly analytical and results-driven
Denials Specialist to join our Revenue Cycle Management team. This role is responsible for resolving complex denied, underpaid, rejected, and aged insurance claims across multiple payer types, with the primary goal of driving claims to final payment while minimizing timely filing losses and avoidable bad debt.
The ideal candidate has extensive experience in medical billing and denial management, is highly proficient in
Cerner, and possesses a deep understanding of payer regulations, denial resolution strategies, appeals, and reimbursement workflows. This position requires someone who can independently manage a high-volume A/R backlog while maintaining exceptional accuracy, productivity, and compliance.
Key Responsibilities
- Manage and resolve a backlog of aged accounts receivable across commercial insurance, Medicare Advantage, Medicaid, and self-pay accounts.
- Investigate and resolve denied, rejected, underpaid, and aged claims across 30-, 60-, 90-, and 120+-day aging buckets.
- Analyze remittance advice, Explanation of Benefits (EOBs), CARC/RARC codes, payer correspondence, and denial language to determine root causes and identify appropriate corrective actions.
- Research complete claim histories to identify issues related to:
- Eligibility and coverage
- Prior authorization and referrals
- Coding and modifier errors
- Medical necessity
- Documentation deficiencies
- Provider credentialing
- Timely filing
- Payer processing errors
- Correct and resubmit claims, including replacement, corrected, and voided claims, following payer-specific guidelines.
- Prepare and submit reconsiderations and formal appeals with all required supporting documentation.
- Utilize payer portals, clearinghouse tools, and payer websites to verify claim status, upload documentation, and monitor appeal activity.
- Monitor timely filing deadlines, appeal timeframes, reconsideration periods, and payer response dates to maximize reimbursement opportunities.
- Bill and support claims across multiple NPIs, including Rural Health Clinic (RHC) and hospital-based entities.
- Work with professional and facility claims, including inpatient, outpatient, Rural Health Clinic, and swing bed services within a Critical Access Hospital environment.
- Navigate billing workflows involving eClinicalWorks (eCW) and Cerner interface processes.
- Identify recurring denial trends by payer, provider, service type, denial category, and root cause, and communicate findings to leadership to support denial prevention initiatives.
- Collaborate with internal billing teams to ensure adherence to billing protocols, workflow improvements, and escalation procedures.
- Maintain complete and accurate account documentation while meeting productivity, quality, and compliance standards.
Qualifications
- Experience with Wisconsin Medicaid billing, denials, corrected claims, and appeals.
- Experience working in a Rural Health Clinic (RHC) and/or Critical Access Hospital (CAH) environment.
- Experience processing inpatient, outpatient, Rural Health Clinic, and swing bed claims.
- Experience billing across multiple NPIs and facility types.
- Familiarity with eClinicalWorks (eCW), particularly within an eCW-to-Cerner interface environment.
- Experience performing denial reporting, root-cause analysis, and implementing denial prevention strategies.
- Professional certification such as:
- Certified Professional Biller (CPB)
- Certified Professional Coder (CPC)
- Or another recognized Revenue Cycle Management certification
Perks
- Permanent Work From Home
- Leave Credits
- Monetary Allowance
- Annual Bonus
- Weekly Paychecks
- Fixed Weekends Off
- Thriving Company Culture with Complete Autonomy
- Exclusive Specialized Training Programs
- Unlock Your Potential with a Highly Competitive Salary
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Who are we
BizForce is one of the fastest-growing global outsourcing companies in the world, founded in the US in Tucson, Arizona and is now operational in PH!
Our Commitment to delivering high-quality results for our clients and the only way to do that is ensuring a rewarding, respectful and productive experience for our employees. We hold the same values for both our customers and our employees.
