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Denials Specialist

Denials Specialist

Phothera PhototherapyBeachwood, OH, United States
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Position Summary

The Denials Specialist is responsible for analyzing, appealing, and resolving denied or underpaid insurance claims. This role requires a detailed understanding of payer policies, strong follow-up skills, and collaboration across billing, coding, and clinical teams to reduce denial rates, secure reimbursement, and improve cash flow.

Key Responsibilities

Denial Analysis & Resolution

  • Review and categorize denied claims by payer, denial reason, and service type.
  • Investigate root causes of denials and identify trends.
  • Correct errors and resubmit claims in a timely manner.
  • Draft and submit clear, evidence-based appeals to payers.

Payer Follow-Up

  • Contact insurance companies to resolve claim denials, underpayments, or pending claims.
  • Maintain up-to-date knowledge of payer policies and medical necessity guidelines.
  • Escalate recurring payer issues to leadership for resolution.

    • Collaboration & Documentation

  • Work with billing, coding, and clinical staff to prevent future denials.
  • Document all actions taken in the practice management / RCM system.
  • Maintain thorough records of appeals, outcomes, and correspondence.

    • Performance Monitoring

  • Track denial overturn rates, recovery amounts, and appeal success rates.
  • Provide feedback to leadership on denial trends and prevention strategies.
  • Assist in staff education on payer rules and common denial issues.

    • Qualifications

  • High school diploma or equivalent required; Associate’s or Bachelor’s degree in Healthcare, Business, or related field preferred.
  • 2+ years of experience in medical billing, claims processing, or denial management.
  • Knowledge of payer requirements, CPT / HCPCS coding, and EOB / ERA interpretation.
  • Strong written and verbal communication skills for effective appeal letters and payer calls.
  • Proficiency in EHR / RCM software and Microsoft Office Suite.
  • Detail-oriented with strong problem-solving and time-management skills.
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    Specialist • Beachwood, OH, United States