Senior Insurance Appeals & Denial Management Specialist
Medical Data SystemsNashville, TN
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Job Description
Job TitleSenior Insurance Appeals & Denial Management Specialist – Hospital Claims (Back-End Only)Job SummaryWe are seeking a highly experienced Back-End Insurance Appeals & Denial Management Specialist to manage hospital claim denials exclusively. This role focuses solely on post-adjudication appeals,underpayment recovery, and payer dispute resolution across multiple third-party payors.Front-end AR, claim submission, and patient balance work are not part of this role.Key Responsibilities
- Manage hospital denials and underpayments from post-adjudication through final resolution
- Prepare and submit first-level, second-level, and external appeals
- Analyze EOBs/RAs, payer policies, and contract language
- Resolve denials related to medical necessity, authorization, coding, DRG validation, timely filing, and reimbursement discrepancies
- Work across commercial and managed care payors
- Escalate complex issues through payer dispute and reconsideration channels
- Document all actions and outcomes in hospital billing systems
- Identify denial trends and provide backend-focused process improvement recommendations
- 5+ years hospital revenue cycle experience with a backend denials focus
- Proven expertise in appeals and denial management only
- Experience resolving high-dollar and complex hospital claims
- Strong understanding of payer contracts and reimbursement methodologies
- Ability to work independently in a high-volume backend environment
- Experience with Epic, Cerner, Meditech, or similar hospital systems
- Revenue cycle, billing, or coding certification (CRCR, CPC, CCS, CPB)
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