Description

The Denial Resolution Specialist (DRS) within the Denial Resource Center (DRC) partners closely with a multi-disciplinary team that includes Registered Nurses, Certified Coding Specialists and Payer Liaisons responsible to resolve high-dollar non-clinical denials, including those of moderate to high complexity. This role requires a strong revenue cycle foundation and deep expertise in payer requirements, denial resolution strategies, and appeal processes to drive accurate and timely reimbursement outcomes.

In addition to resolving denials, the DRS is instrumental in identifying trends, root causes and process gaps, and proactively reporting insights to DRC clinical leadership to inform denial prevention strategies, improve workflows and enhance overall revenue cycle performance.

SALARY

The pay range for this position is $28.52 (entry-level qualifications) - $42.79 (highly experienced) The specific rate will depend upon the successful candidate's specific qualifications and prior experience

ESSENTIAL FUNCTIONS of the ROLE

• Review and analyze denied claims to determine appropriate resolution or appeal strategy.

• Interpret EOBs, remittance codes, payer policies, and contract terms to support accurate adjudication review.

• Prepare and submit clear, concise, and compliant appeal documentation for non-clinical denials (e.g., authorization and contract-related).

• Initiate and track retrospective authorization requests in accordance with payer requirements.

• Conduct timely follow-up with payers via phone and portal; escalate unresolved or high-risk accounts as appropriate.

• Maintain accurate documentation and status updates within patient accounting systems to ensure audit readiness.

• Monitor work queues and appeal deadlines to ensure timely processing.

• Collaborate with clinical team members and internal stakeholders on complex cases and escalation pathways.

• Identify denial trends and root causes; communicate findings and support process improvement and prevention efforts.

• Reconcile assigned inventory, including accounts referred to external vendors, and ensure accuracy and timeliness of resolution.

KEY SUCCESS FACTORS

• High school diploma or GED required; Associate's degree preferred.

• CRCR (Certified Revenue Cycle Representative) certification preferred.

• 4+ years of experience in medical billing, revenue cycle operations, or denial and appeals management.

• Experience within a hospital or health system revenue cycle environment required.

• Working knowledge of payer guidelines, reimbursement methodologies, and denial/appeal processes.

• Familiarity with clinical workflows and strong relationship building skills with clinical teams is a strong plus.

• Proficiency in Microsoft Office applications and revenue cycle systems; Epic experience required.

• Strong analytical skills with the ability to interpret remits, payer responses, and supporting documentation.

• Effective written and verbal communication skills, with the ability to draft clear and professional correspondence.

• Demonstrated ability to work independently, manage priorities, and consistently meet deadlines in a high-volume environment.

QUALIFICATIONS

• EDUCATION - H.S. Diploma/GED Equivalent

• EXPERIENCE - 4 Years of Experience