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Job description
Role Description
The Revenue Cycle Denials Representative is responsible for managing and resolving denied Professional Billing (PB/CMS-1500) and/or Hospital Billing (HB/UB-04) claims. This role identifies root causes of denials, executes appeals and corrective actions, and collaborates with internal teams to prevent future denials. The ideal candidate has hands-on experience with CARC/RARC denial codes, Epic denial work queues, and payer-specific appeal requirements across Medicare, Medicaid, and commercial payers.
Roles & Responsibilities
Denial Review & Resolution - PB & HB
Review and analyze denied PB (CMS-1500 / 837P) and HB (UB-04 / 837I) claims to determine root causes and appropriate resolution strategies.
Analyze account history and all previous actions in Epic prior to taking the next action step to resolve the claim.
Work claims across all top denial categories including, but not limited to: No Authorization, Timely Filing, Coordination of Benefits (COB), Medical Necessity, Additional Documentation Requests (ADR), Bundling (NCCI edits), and Duplicate Claims.
Interpret CARC and RARC codes on 835 ERA / EOB remittance data for both PB and HB claims to determine the correct resolution path.
Understand when claim corrections, rebilling (837P or 837I), or void-and-replace actions are appropriate.
Escalate claims with payers for resolution when processing is inaccurate or delayed.
Appeals & Reconsiderations
Prepare and submit appeals and reconsideration requests in compliance with payer-specific guidelines and deadlines for both PB and HB denied claims.
Attach appropriate clinical documentation, medical records, authorization references, and justification letters to support appeal submissions.
Meet appeal deadlines for Medicare, Medicaid, and commercial payers in accordance with payer-specific requirements.
Trend Identification & Prevention
Identify denial trends across PB and HB claim types and collaborate with coding, clinical, and billing teams to implement corrective actions.
Monitor payer policy and regulatory changes (Medicare LCDs/NCDs, Arkansas Medicaid updates) to proactively prevent denials.
Assist in developing best practices and training materials for PB and HB denial management and prevention.
Payer & System Knowledge
Navigate Epic denial and underpayment work queues for both HB and PB modules; document all denial actions and resolutions.
Utilize payer portals (Availity, Arkansas DHS, Medicare.gov, and commercial payer sites) to research denial reasons and submit appeals.
Utilize resources provided by the client to promote accuracy and resolve claims in accordance with client expectations.
Compliance & Documentation
Maintain thorough documentation of denial reasons, appeal actions, and resolutions in Epic.
Ensure compliance with federal, state, and payer regulations as well as hospital and physician practice policies.
Communicate effectively with insurance representatives and internal leaders to expedite resolution and improve processes.
Always maintain confidentiality of patient and account information (HIPAA).
Adhere to prescribed policies and procedures outlined in the Employee Handbook and Code of Conduct.
Maintain awareness of and actively participate in the Corporate Compliance Program.
Maintain a confidential and orderly remote work area.
Meet specified goals and objectives assigned by management and/or the Client.
Assist with other projects as assigned by management.
Expected / Key Results
Deliver high levels of client and patient satisfaction (CSAT)
Achieve quality scores per defined process standards
Deliver defined process-specific metrics (e.g., denial resolution rate, overturn rate, appeal success rate)
Adherence to regulatory compliance requirements
Schedule adherence
Preferred Educational Qualifications
High school diploma or equivalent required
Associate's or Bachelor's degree in Health Information Management, Business, or related field preferred
CPC, CPMA, CRCR, or CHFP certification a plus
Preferred Work Experience
2+ years of experience in healthcare revenue cycle, denial management, or claims resolution
Demonstrated experience working PB (CMS-1500 / 837P) and/or HB (UB-04 / 837I) denials
Prior experience with Epic denial work queues strongly preferred
Familiarity with Medicaid, Medicare, and commercial payers preferred
Experience interpreting CARC/RARC codes and 835 ERA / EOB remittance data
Knowledge of NCCI edits, LCD/NCD policies, and authorization/pre-certification workflows
Competencies & Skills
Strong knowledge of PB and HB denial workflows, appeal processes, and payer-specific requirements
Proficiency with Epic (HB and/or PB modules, denial work queues, claim correction, void-and-replace, and rebilling)
Solid understanding of CARC/RARC denial reason codes and how to act on them for PB and HB claims
Ability to read and interpret 835 ERA / EOB remittance advice for both PB and HB claims
Knowledge of payer portals including Availity, Arkansas DHS, and commercial payer sites
Competent in working and communicating effectively with payers, patients, colleagues, and management - both in-person and via remote virtual platforms
Consistently maintains a courteous and professional demeanor
Self-motivated with the ability to stay focused and productive with minimal supervision
Proactive initiative and creative problem-solving in carrying out job responsibilities
Ability to prioritize multiple tasks through effective time management and organizational skills
Proficiency in PC operations; ability to type at a rate of 30-40 words per minute
Benefits including but not limited to: Medical, Vision, Dental, 401K, Paid Time Off.
We are an Equal Opportunity Employer. All qualified applicants are considered for employment without regard to race, color, age, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by federal, state or local law.
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