Medical Data Systems

Compensation

Full Description

Job Title Senior Insurance Appeals & Denial Management Specialist – Hospital Claims (Back-End Only) Job Summary We 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 Required Qualifications • 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 Preferred • Experience with Epic, Cerner, Meditech, or similar hospital systems • Revenue cycle, billing, or coding certification (CRCR, CPC, CCS, CPB)