Job Role Description

Medical/Healthcare > Denials & Appeals Specialist

Salary National Average

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Short Description:

A Denials & Appeals Specialist is responsible for managing and resolving denied insurance claims by investigating issues, preparing appeal documentation, and communicating with payers and healthcare providers. They analyze claim denials, identify errors or missing information, and develop strategies to maximize reimbursement. The role involves maintaining detailed records, tracking appeal progress, and ensuring compliance with regulatory and organizational policies. Denials & Appeals Specialists help optimize revenue cycle performance and improve payer relations. Strong analytical, problem-solving, and communication skills are essential for success in this role.

Duties / Responsibilities:

  • Review denied claims from insurance payers to determine the reason for denial and assess appeal viability
  • Prepare and submit appeal letters, supporting documentation, and follow-up materials in compliance with payer requirements
  • Collaborate with clinical staff, coding teams, and billing departments to gather necessary medical records and documentation for appeals
  • Monitor claim status and track timelines to ensure timely submission and resolution of appeals
  • Analyze trends in claim denials to identify recurring issues and recommend process improvements
  • Communicate with insurance companies, clients, and internal teams to resolve disputes and clarify claim details
  • Maintain accurate records of denied claims, appeals, and outcomes for auditing and reporting purposes
  • Assist in developing and updating policies, procedures, and guidelines for denials management
  • Generate reports on appeal success rates, common denial reasons, and outstanding claims for management review
  • Stay current on payer policies, healthcare regulations, and coding guidelines to optimize claim recovery

Skills / Requirements / Qualifications

  • Education: High school diploma required; associate’s or bachelor’s degree in healthcare administration, finance, or related field preferred
  • Experience: 2–4 years of experience in medical billing, claims processing, or denial management
  • Technical Skills: Proficiency with EHR systems, claims management software, and Microsoft Office Suite
  • Analytical Skills: Ability to interpret claim denials, review documentation, and develop effective appeal strategies
  • Attention to Detail: Accuracy in reviewing claims, compiling documentation, and tracking appeal progress
  • Communication: Strong verbal and written communication skills for interacting with insurers, clinical staff, and internal teams
  • Problem-Solving: Ability to investigate denials, identify root causes, and implement corrective actions
  • Regulatory Knowledge: Understanding of healthcare regulations, coding standards, and payer requirements relevant to claim denials and appeals

Job Zones

  • Title: Job Zone Three: Medium Preparation Needed.
  • Education: Most occupations in this zone require vocational school training, on-the-job experience, or an associate's degree.
  • Related Experience: Previous work-related skill, knowledge, or experience is required for these occupations. 
  • Job Training: Employees in these occupations usually need one or two years of on-the-job experience and informal training with experienced workers. A recognized apprenticeship program may be associated with these occupations.
  • Job Zone Examples: These occupations usually involve communication and organizational skills to coordinate, supervise, manage, or train others to accomplish goals. 
  • Specific Vocational Preparation in years: 1-2 years preparation (6.0 to < 7.0)

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