Denials & Appeals Specialist

Overview

Company Summary

If you are searching for a fulfilling place to develop your career and an opportunity to make a difference in helping others, then keep reading on. Here at AAC, we have a progressive culture; we listen to your ideas, value a work/life balance, invest in education, and we foster trust and respect for all individuals. Our exceptional comp and strong benefits include company matching 401K, medical, dental, vision and life insurance. We are looking for our future leaders, who are not only going to fill the qualifications for this job description, but who are going to exceed expectations. Be a part of a team whose mission is to provide quality, compassionate, and innovative care to adults struggling with addiction and co-occurring mental health disorders. Our purpose and passion are to empower patients, their families, and our communities by helping individuals achieve recovery and optimal wellness of the mind, body, and spirit.

Responsibilities

Job Summary

The Denials & Appeals Specialist is responsible for investigating, resolving, and appealing denied insurance claims from third-party payers. This role focuses on analyzing unpaid and denied claims, identifying the root cause of the denial, and executing effective resolution strategies to recover revenue and minimize organizational write-offs. The ideal candidate possesses a deep understanding of medical coding, payer guidelines, and the health insurance revenue cycle.

Duties and Responsibilities:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.

The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Denial Analysis & Research

• Review and analyze insurance claim denials and rejections utilizing Electronic Health Records (EHR) and Explanation of Benefits (EOB) / Remittance Advices (RA).
• Identify the specific reason for denial (e.g., medical necessity, missing prior authorization, coding errors, coordination of benefits, or eligibility issues).
• Research payer-specific policies, guidelines, and deadlines to determine the validity of the denial.

Appeals & Resolution Management

• Prepare and submit formal, clinical, or administrative appeal letters with necessary supporting documentation (medical records, doctor's notes, proof of timely filing).
• Correct and re-submit modified claims using appropriate modifiers, ICD-10, and CPT codes.
• Routinely contact insurance companies via telephone or provider portals to track the status of appeals and expedite resolution. 

Collaboration & Communication

• Partner with Medical Coding, Billing, and Clinical teams to obtain missing documentation or clarify coding discrepancies.
• Educate internal departments on recurring denial trends to prevent future claim rejections.
• Maintain professional and timely communication with insurance representatives, management, and internal teams.

Tracking & Reporting

• Accurately document all actions taken, correspondence received, and appeal statuses in the patient account ledger and billing system.
• Monitor accounts receivable (A/R) aging reports to ensure timely follow-up within strict payer-imposed deadlines.
• Assist in generating reports on denial trends, appeal success rates, and recovered revenue.

Qualifications

Education/ Experience:

Education: High School Diploma or GED equivalent required; Associates or Bachelor’s degree in Healthcare Administration or related field preferred.

Experience: 2–4 years of experience in healthcare billing, medical collections, or accounts receivable, with a dedicated focus on insurance denial management.

Certifications: Certified Professional Coder (CPC) or Certified Revenue Cycle Representative (CRCR) is highly preferred but not always required.

Technical & Soft Skills

Coding Knowledge: Strong proficiency in ICD-10-CM, CPT, and HCPCS coding, as well as UB-04 and CMS-1500 claim formats.

Systems: Experience with major healthcare revenue cycle platforms (e.g., Epic, NextGen, eClinicalWorks) and insurance web portals (e.g., Availity).

Attention to Detail: Meticulous approach to reviewing complex clinical documentation and legal insurance contracts. AppleOne Communication: Excellent written and verbal communication skills, specifically for drafting persuasive appeal letters.

Problem Solving: Strong analytical skills to troubleshoot complex claim histories and find creative resolution pathways.

Physical Requirements

“AAC is committed to principles of equal opportunities for all employees.  The Company will provide reasonable accommodations to comply with State and Federal disability discrimination laws.”

• Prolonged sitting at a desk
• Must be able to lift 15 pounds at a time

American Addiction Centers is an equal opportunity employer.  American Addiction Centers prohibits employment practices that discriminate against individuals or groups of employees on the basis of age, color disability, national origin, race, religion, sex, sexual orientation, pregnancy, veteran or military status, genetic information or any other category deemed protected by state and/or federal law.

Compensation Transparency: In accordance with the Massachusetts Pay Transparency Act, the reasonable estimate of the pay range for this position $25.62-$34.61 flat rate per hour. Actual compensation within this range will depend on the candidate’s skills, experience, education, and relevant qualifications. Generally, placement within the upper portion of the range is reserved for candidates with several years of directly related experience or exceptional expertise.