Full-Time Senior Appeals Specialist

Position Overview

The Sr Appeals Specialist will be responsible for designing and implementing an appeal strategy to optimize reimbursement success and reduce claim denials. Reporting to the Senior Manager of Reimbursement Operations, this individual contributor role focuses on enhancing the appeals process, from identifying root causes of denials to creating workflows and templates that increase successful appeals. This role will collaborate closely with the payor relations team as well as of the rest of reimbursement operations and external vendors to ensure consistent, compliant, and effective appeals handling across the organization.

Key Responsibilities and Essential Functions

• Develop and implement an appeals strategy that reduces denial rates and improves reimbursement outcomes.
• Conduct thorough root-cause analysis of denied claims, identifying patterns and developing strategies to address systemic issues.
• Create, maintain, and optimize appeal templates, documentation standards, and workflows to streamline the appeals process.
• Work cross-functionally with billing, prior authorization, and insurance verification teams to coordinate efforts and enhance appeals effectiveness.
• Monitor regulatory changes and payer policies, ensuring appeal practices remain compliant and adjusting strategies as needed.
• Track, analyze, and report on appeal outcomes, providing insights to management to support continuous improvement in reimbursement processes.
• Establish key performance indicators (KPIs) for appeal effectiveness and develop data-driven recommendations for ongoing optimization.
• Serve as the subject matter expert on appeal processes, providing guidance, training, and support to reimbursement operations staff.
• Collaborate with IT and analytics teams to develop tools and dashboards that facilitate tracking and reporting on appeal metrics.
• In coordination with the Payor Relations team engage with payers, as necessary, to resolve high-priority appeals and maintain productive relationships that support favorable outcomes.

Position Requirements (Education, Experience, Other)

Required

• Bachelor’s degree + 5 years of experience in healthcare and/or life sciences
• 5+ years of experience in healthcare reimbursement, with a focus on claims appeals, denials management, or related areas.
• In-depth knowledge of medical billing and coding standards, including ICD-10, CPT, and payer guidelines.
• Demonstrated experience in developing appeal strategies or processes in a healthcare setting.
• Strong analytical skills, with the ability to identify trends and develop actionable strategies based on data.
• Excellent written and verbal communication skills for effectively communicating with internal stakeholders and payers.
• Detail-oriented and highly organized, with a proactive approach to managing complex appeal cases. Ability to work collaboratively in a cross-functional environment
• Experience with revenue cycle management in a CLIA-certified laboratory or similar healthcare setting.
• Familiarity with healthcare software solutions and data visualization tools, such as Tableau or Power BI.
• Knowledge of payer policies, reimbursement regulations, and healthcare compliance standards.
• Proven ability to work independently, manage multiple tasks, and prioritize in a fast-paced environment.