Medical Claims and Denials Specialist

Job Summary:

The Medical Claims and Denials Specialist is responsible in reviewing, analyzing, and resolving denied or underpaid medical claims to maximize reimbursement. The role identifies root causes, prepares appeals, and collaborates with internal teams to reduce denial rates and improve revenue cycle performance.

Tasks and Responsibilities:

• Reviews and analyzes denied or underpaid medical claims across multiple specialties (e.g., primary care, urgent care, behavioral health, imaging).
• Investigates root causes of denials, including coding errors, authorization issues, eligibility, and documentation deficiencies.
• Prepares and submits timely and accurate appeals to insurance carriers.
• Follows up with payers via phone, portals, and online systems to ensure resolution of outstanding claims.
• Tracks and documents all denial activities in billing systems.
• Identifies trends and recurring issues and reports findings to management.
• Collaborates with coding and clinical teams to correct documentation and coding errors.
• Recommends workflow improvements to reduce future denials.
• Maintains knowledge of payer policies, CPT, ICD-10, HCPCS guidelines, and regulatory requirements.
• Meets productivity and quality benchmarks for denial resolution.

Qualifications:

• Minimum of two (2) years of experience in medical billing, accounts receivable, or denial management.
• Experience handling denied or underpaid claims and appeals.
• Familiarity with Athenahealth system.
• Demonstrates strong knowledge of CPT, ICD-10, and HCPCS coding systems.
• Demonstrates strong understanding of medical billing, payer guidelines, and appeals processes.
• Demonstrates strong analytical, problem-solving, and organizational skills.
• Shows the ability to identify denial trends and recommend corrective actions.
• Clear and coherent both written and verbal communication skills in English, to effectively coordinate payer interactions and internal collaboration.

Work Location: WFH (within PH only)

Work Schedule: 10PM-7AM PHT (Sat-Sun off)

What is in store for you

• Rice Allowance
• Internet Allowance
• Overtime Pay
• Holiday Pay
• 25% Night Differential
• Perfect Attendance Bonus (terms apply
• 20 days Paid Time Off per year (1.67 days earning every month)
• HMO for Employee
• HMO for Dependents
• Group Life Insurance
• Annual Merit Increase (terms apply)
• 13th Month Pay
• Mid-Year Bonus (terms apply)