JOB POSTING
Job Description
Title: Claims Denial and Appeals Specialist
Location: 555 MidTowne NE, Grand Rapids, MI 49503
Hours: Full-Time (40 Hours/Week) - Office hours are M-F, 7AM-5PM (Flexibility to choose your start time between the hours of 7-8:30AM, schedule would then be the same each day)
Work Environment: Onsite
About Us
Orthopaedic Associates of Michigan (OAM) is proud to be West Michigan’s most established orthopaedic practice. Our physicians and team members provide exceptional, individualized care for patients of all ages. As the most comprehensive independent provider of musculoskeletal care in the region, we provide total care from diagnosis, to treatment, and all the way through rehabilitation.
Patients at OAM will have access to our Specialized Surgeons, Physical and Occupational Therapists, MRI and X-ray services, and orthopaedic bracing. Patients are also able to receive care from our Bone Health Clinic, OAM Now Urgent Orthopaedic Care Clinic, and Surgery Center at MidTowne – all of which are committed to optimizing their treatment outcomes.
Our teams work together to maximize and adjust treatment quickly and easily, resulting in a smoother, faster recovery for patients. From neck to toe, and from traumatic injuries to chronic conditions, patients will receive compassionate care that will allow them to embrace their full potential. Patient goals are our goals – we will restore their health so they are functioning as fully as possible in the activities they love at home, work, and in everyday life.
Position Summary
The Claims Denial & Appeals Specialist is responsible for reviewing, analyzing, and resolving denied or underpaid insurance claims to ensure accurate and timely reimbursement. This role serves as a key resource in managing accounts receivable by investigating claim denials, preparing appeals, monitoring payer reimbursement activity, and identifying denial trends. The position works directly with insurance carriers, patients, and internal departments to support revenue cycle integrity and improve reimbursement outcomes. The Claims Denial & Appeals Specialist also assists with financial counseling, payer communications, and account reconciliation activities while maintaining compliance with HIPAA and organizational policies.
Supervision
This position has no direct reports.
Essential Responsibilities
- Review and analyze denied insurance claims to determine appropriate appeal and reimbursement actions.
- Research denial reasons and prepare supporting documentation necessary for claim appeals.
- Communicate directly with insurance payers regarding denied, underpaid, or inaccurately processed claims.
- Resubmit denied or corrected claims to ensure appropriate reimbursement.
- Audit patient accounts to verify payments, balances, contractual adjustments, coding accuracy, and claim status.
- Monitor reimbursement activity and notify leadership of payment variances or discrepancies.
- Identify, document, and communicate denial trends and recurring reimbursement issues.
- Recommend process improvements and system enhancements to reduce future claim denials.
- Collaborate with payers to understand denial causes and implement preventative measures.
- Process insurance refunds accurately and timely following receipt of payments and explanation of benefits (EOBs).
- Review aged accounts receivable reports and pursue outstanding patient and insurance balances.
- Coordinate with the Business Office Manager on daily and monthly accounts receivable reconciliation activities.
- Provide financial counseling to patients and assist with approved payment arrangements.
- Access and maintain payer websites to obtain authorization, eligibility, and claim status information.
- Protect confidential payer portal credentials and sensitive information.
- Maintain accurate and up-to-date patient account documentation.
- Respond to patient and insurance inquiries in a professional and timely manner.
- Assist with departmental coverage and support team members as operational needs require.
- Participate in cross-training efforts within Business Office functions including insurance verification and medical records.
- Meet productivity, quality, and timeliness standards established by management.
- Perform other duties as assigned.
Required & Preferred Qualifications
Education, Training, and Experience:
- Required:
- High school diploma, GED, or equivalent.
- Minimum of one (1) year of experience in medical billing, insurance appeals, accounts receivable, revenue cycle, or a related healthcare business office function.
- Knowledge of third-party payer reimbursement methodologies and insurance claim processing.
- Knowledge of CPT, ICD-10-CM, HCPCS, and applicable modifiers.
- Working knowledge of HIPAA regulations and confidentiality requirements.
- Preferred:
- 1-2 years of college coursework, vocational training, or equivalent healthcare revenue cycle education.
- Experience with computerized patient accounting systems.
- Experience with electronic remittance processing and payer portal management.
- Previous experience in an ambulatory surgery center, orthopedic practice, or healthcare setting.
*An equivalent combination of education and experience may be considered.*
Specific Skills, Knowledge, and Abilities:
- Excellent written and verbal communication skills.
- Strong customer service and patient relations skills.
- Proficiency in Microsoft Office applications.
- Strong analytical and problem-solving abilities.
- Ability to independently manage multiple priorities and deadlines.
- Strong organizational and time management skills.
- Effective interpersonal skills with the ability to work collaboratively across departments.
- Ability to maintain professionalism and confidentiality when handling sensitive information.
- Ability to interpret payer guidelines, contracts, and reimbursement policies.
- Ability to adapt to changing priorities in a fast-paced healthcare environment.
Motor, Sensory, and Physical Requirements:
- Ability to sit and/or stand for prolonged periods of time.
- Manual dexterity required to operate modern office equipment.
- Ability to frequently handle files, records, and medical charts.
- Frequent bending, reaching, and light lifting required.
- Ability to lift up to 20 pounds.
- Normal or correctable range of hearing and eyesight.