Qualifications

·   Education

·   Licensure

·   Work Experience

·   Skills/computer/ specific technical

§ Other qualifications, miscellaneous 

Specify if qualifications are Required or Preferred 

•     Associate's or Bachelor's degree in Health Information Management, Healthcare Administration, Nursing, or a related field preferred; equivalent work experience considered. 

•     Minimum of 2-4 years of experience in medical billing, claims denial management, appeals, utilization review, or revenue cycle operations. 

•     Working knowledge of ICD-10, CPT, and HCPCS coding, medical terminology, and payer reimbursement methodologies. 

•     Familiarity with Medicare, Medicaid, and commercial payer denial and appeal guidelines. 

•     Certified Coding Specialist (CCS), Certified Professional Coder (CPC), or Certified Revenue Cycle Representative (CRCR) credential a plus. 

•     Proficiency with electronic health record (EHR) and practice management/billing systems. 

•     Strong written and verbal communication skills, with the ability to construct clear, evidence-based appeal letters. 

Essential Job Responsibilities

Achieving Results 

Key Components: assess, plan, evaluate, demonstrate initiative, quality of work, productivity 

·         Meets or exceeds established productivity and turnaround-time targets for denial resolution and appeal submission. 

·         Successfully overturns a measurable percentage of denied claims through accurate, well-documented appeals. 

·         Prioritizes workload effectively to meet payer-specific filing deadlines and avoid timely-filing losses. 

·         Tracks outcomes and follows through until each denial is resolved, escalated, or closed appropriately. 

Demonstrates Skill 

Key Components: competency, job knowledge, organizational skills, analytical skill, management of information, employee & patient safety 

Technical Expertise

•       Expert-level understanding of denial types (clinical necessity, coding, authorization, timely filing, COB) and corresponding appeal strategies.

•       Strong command of payer contracts, fee schedules, and reimbursement logic across Medicare, Medicaid, and commercial lines of business.

•       Proficiency in hospital billing and revenue cycle systems (Epic) and payer web portals.

•       Familiarity with denial management and workflow automation platforms (e.g., Kodiak, Optum360, Availity).

•       Working knowledge of clinical documentation requirements, ICD-10-CM/PCS coding principles, and clinical criteria sets (InterQual, Milliman).

Planning & Coordinating 

Key Components: delegates, decision making, problem solving, management of resources 

·         Organizes and manages a high-volume caseload of denials and appeals to ensure timely, orderly processing. 

·         Coordinates with coding, clinical documentation, case management, and billing teams to gather supporting documentation. 

·         Maintains an organized tracking log or dashboard of denial status, appeal deadlines, and outcomes. 

·         Schedules and leads regular denial-trend review meetings with relevant stakeholders. 

Professionalism

Key Components: dependability, interpersonal skills, teamwork, patient first ethic, customer service, communication skills, punctuality/attendance, receptiveness to criticism, judgment, confidentiality

•       Maintains confidentiality of patient information in accordance with HIPAA and organizational policy. 

•       Communicates respectfully and collaboratively with payers, providers, and internal departments. 

•       Represents the organization professionally in all written and verbal payer interactions. 

•       Exercises sound judgment and integrity when handling sensitive financial and clinical information.