Denials Specialist Senior - Medical Bill Audit

Under the direction of the Asst Director Denials & Medical Billing Audit, the Senior Denials Specialist is responsible for the comprehensive review, analysis, and resolution of denied hospital claims through the appeals process to ensure optimal reimbursement for Tampa General Hospital. This role serves as a subject matter expert in Medicare, Medicaid, and third-party payer regulations, contract language, and federal, state, and county billing guidelines. The Senior Denials Specialist actively supports denial avoidance initiatives, maintains payer relationships, and ensures the integrity of claim development and submission processes. The position collaborates with internal departments, external payers, and regulatory entities while performing all duties in alignment with the mission, vision, and values of Tampa General Hospital.

Essential Functions:

• Reviews denied inpatient and outpatient claims to determine appeal eligibility, accuracy, and compliance with payer and regulatory requirements.
• Executes the full denial appeal process, including preparation, submission, documentation, tracking, and timely follow-up of appeals.
• Analyzes payer contracts and reimbursement methodologies to validate adjustments and identify underpayments or incorrect denials.
• Conducts denial avoidance reviews and provides reporting and recommendations to prevent recurring denial patterns.
• Maintains accurate and detailed documentation of all payer communications, appeals activity, and resolution outcomes.
• Researches payer policies, regulatory updates, and industry best practices to ensure compliance and continuous process improvement.
• Collaborates with nursing, coding, case management, revenue integrity, IT, and other departments to resolve denial issues and improve workflows.
• Communicates professionally with third-party payers, including responding to inquiries, resolving disputes, and coordinating arbitration when necessary.
• Tracks and analyzes denial trends, prepares reports, and presents findings to leadership to support performance improvement and financial goals.
• Trains and mentors new staff, provides feedback to management, and promotes a culture of teamwork, accountability, and customer service.
• High School Diploma or GED.
• Five (5) years of Hospital experience in billing and collecting Medicare/Medicaid/Commercial; working knowledge of Federal, State and County guidelines as it relates to billing; and knowledge of electronic billing systems.

Technical Knowledge, Skills, and Abilities:

• In-depth knowledge of Medicare, Medicaid, and commercial payer billing, collection, and appeals processes, including applicable federal, state, and county regulations.
• Demonstrated ability to interpret payer contracts, analyze denial reasons, identify root causes, and determine appropriate appeal strategies.
• Advanced understanding of hospital revenue cycle operations, including claim development, denial prevention, appeal submission, tracking, and follow-up.
• Strong ability to research complex denial issues, analyze trends, maintain denial data, and recommend process improvements to enhance cash flow and reduce denials.
• Excellent verbal and written communication skills to effectively interact with payers, government agencies, leadership, and interdisciplinary hospital teams.
• Proficient in electronic billing systems, denial management tools, and reporting applications used to track, document, and analyze claims and appeals activity.