Denials and Appeals Specialist (Level 3)

What your day will look like

• Resolve highly complex and high-dollar reimbursement issues.
• Perform root cause analysis on denial trends and payer behavior.
• Manage systemic payer issues affecting multiple claims or locations.
• Serve as the escalation point for Level 1 and Level 2 AR Specialists**, including the resolution of the most complex patient account and payer concerns.**
• Handle sensitive and complex patient interactions, providing advanced problem-solving and de-escalation for challenging account issues.
• Develop advanced appeal strategies and resolution pathways.
• Interpret complex payer policies, coding rules, and reimbursement logic.
• Identify breakdowns in payer processes and recommend corrective action.
• Support process improvement initiatives across the revenue cycle.
• Provide guidance on complex claim scenarios and payer disputes.
• Review and approve account write-offs and adjustments up to $1,000; escalate amounts exceeding this threshold for management approval.
• Assist with standard Level 1 and Level 2 Accounts Receivable responsibilities across all financial classes as business needs require.

Knowledge & Skills Needed to be Successful

• Exceptional ability to investigate complex data sets, perform root cause analysis on denial trends, and solve ambiguous billing or reimbursement puzzles independently
• Expert-level mastery of insurance workflows, advanced appeal strategies, coding rules, and diverse payer reimbursement logic
• Strong capacity to navigate high-dollar disputes and confidently implement advanced resolution pathways under minimal supervision
• Ability to articulate complex policy concepts clearly, serving as an approachable technical resource and mentor to junior staff
• Excellent written and verbal communication skills
• Ability to prioritize and manage multiple workflows and deadlines
• Must possess the ability to maintain effective working relationships with patients, medical staff and the public
• Must possess the ability to react calmly and effectively in a difficult or emergent situation, including de-escalating sensitive patient concerns. 

• Direct Supervision: This role does not have formal direct reports (e.g., hiring, firing, or formal performance reviews).
• Functional Leadership: Acts as an informal technical authority and team lead within the AR department.
• Escalation & Mentorship: Responsible for monitoring, guiding, and reviewing the work of Level 1 and Level 2 AR Specialists on escalated, high-dollar cases to ensure accurate resolution.
• Conduct 1:1 meetings with department and cross-departmental teams to share denial trends.

Required Education and Experience:

• Minimum of 5–7 years of medical billing, collections, and accounts receivable experience within a healthcare environment.
• Proven track record of independently resolving high-dollar, complex denials and dealing directly with difficult payer scenarios.
• Advanced proficiency with electronic health record (EHR) systems, clearinghouses, and medical billing software.
• High School Diploma or higher

• Certified Revenue Cycle Specialist (CRCS), Certified Professional Coder (CPC), or equivalent revenue cycle certification.
• Prior experience in a "Tier 3" or Senior/SME AR role, or experience auditing insurance reimbursement workflows.
• Experience utilizing data analytics tools (e.g., advanced Excel, Tableau, or Power BI) to track and report on denial trends.
• Experience in Allergy & Sinus Specialty 
• Experience with NextGen EHR
  
  

• Medical, Dental and Vision Insurance
• Generous Paid Time Off and Paid Holidays
• 401(k) + Generous Employer Match
• Life Insurance
• Gym Membership Discounts

Reports To