The Onyx Group - Denial & AR Follow-Up Specialist

Job description

Job Title: Denials & AR Follow-Up Specialist Weekly Hours: 40 hours per week, Schedule Options (Onsite): Monday – Friday, 8:00 AM – 5:00 PM (1-hour lunch) or Monday – Friday, 8:00 AM – 4:30 PM (30-minute lunch) Supervised by: Denials & AR Follow-Up Team Lead / Revenue Cycle Manager Position Overview: The Denials & AR Follow-Up Specialist is responsible for the analysis, follow-up, and resolution of denied, underpaid, and unpaid insurance claims to maximize reimbursement and reduce outstanding accounts receivable. This role serves as a subject matter expert in payer reimbursement methodologies, denial management, appeals processing, and revenue recovery strategies. The Denials & AR Follow-Up Specialist performs complex account research, identifies root causes impacting reimbursement, prepares appeals, and collaborates with internal departments to resolve barriers to payment. This position plays a critical role in protecting organizational revenue through effective denial prevention, reimbursement recovery, and accounts receivable management. Responsibilities: Denials Management · Review, analyze, and resolve denied claims across commercial, government, and managed care payers. · Identify denial root causes including coding, authorization, eligibility, credentialing, registration, documentation, and payer processing issues. · Prepare and submit first-level, second-level, and complex appeals within payer filing deadlines. · Obtain and review medical records, referrals, authorizations, operative reports, and supporting documentation necessary for appeal submissions. · Monitor appeal status and perform ongoing follow-up until final claim resolution. · Escalate payer trends and unresolved denial issues as appropriate. Accounts Receivable Follow-Up · Maintain an assigned inventory of accounts receivable and work accounts according to departmental productivity and aging standards. · Perform comprehensive account research to identify barriers preventing reimbursement. · Contact insurance carriers through payer portals, correspondence, and direct communication to resolve outstanding balances. · Pursue payment on denied, partially paid, and unpaid claims. · Identify and resolve reimbursement discrepancies, payment variances, and payer processing errors. · Ensure all follow-up activities are documented accurately and timely within the billing system. Revenue Recovery & Reimbursement Analysis · Analyze Explanation of Benefits (EOBs), Electronic Remittance Advice (ERAs), payer correspondence, and contractual reimbursement expectations. · Investigate underpayments and payment variances to ensure accurate reimbursement. · Review payer guidelines, contracts, and policies to support reimbursement recovery efforts. · Recommend corrective actions to improve reimbursement outcomes and reduce future denials. · Identify opportunities for revenue recovery and process improvement. Root Cause Analysis & Denial Prevention · Identify recurring denial trends and reimbursement obstacles. · Partner with Coding, Credentialing, Registration, Authorizations, Cash Posting, Credits, and Billing teams to resolve systemic issues. · Provide feedback regarding operational, workflow, or system issues contributing to denials. · Participate in denial prevention initiatives and revenue cycle improvement projects. · Assist leadership in identifying opportunities to improve clean claim rates and reduce accounts receivable aging. System Utilization & Documentation · Utilize Epic and/or eClinicalWorks (eCW) to review claim activity, account history, and reimbursement information. · Utilize Waystar, FinThrive, payer portals, and other revenue cycle technologies to research and resolve claims. · Maintain accurate and complete account documentation supporting all actions taken. · Ensure account notes support audit readiness and operational transparency. Compliance & Quality · Maintain compliance with CMS regulations, payer requirements, HIPAA standards, and organizational policies. · Ensure appeals and follow-up activities meet payer filing deadlines. · Maintain high levels of accuracy, quality, and productivity. · Support internal and external audit requests as needed. Key Outcomes / Performance Expectations · Reduction in aged accounts receivable inventory. · Increased denial overturn and appeal success rates. · Timely resolution of denied, underpaid, and unpaid claims. · Recovery of reimbursement that may otherwise be written off. · Accurate account documentation and claim follow-up activities. · Identification and communication of denial trends and systemic reimbursement issues. · Achievement of productivity, quality, and aging performance goals. Required Education & Certifications: · High School Diploma or equivalent required. · Associate's or Bachelor's degree preferred. · Minimum of 3–5 years of healthcare revenue cycle experience required. · Minimum of 2 years of direct experience in denials management, insurance follow-up, accounts receivable resolution, or reimbursement recovery required. · Experience working with physician practice billing, professional claims, and multi-specialty healthcare organizations preferred. Knowledge & Skills · Advanced knowledge of healthcare reimbursement methodologies and insurance claims processing. · Strong understanding of denial management, appeals processes, and payer regulations. · Working knowledge of CPT, ICD-10-CM, HCPCS, modifiers, and medical necessity requirements. · Ability to interpret EOBs, ERAs, payer policies, and reimbursement guidelines. · Strong analytical and critical thinking skills. · Excellent problem-solving and root cause analysis abilities. · Strong organizational skills with the ability to manage a high-volume workload. · Effective written and verbal communication skills. Systems Experience Preferred experience with: · Epic · eClinicalWorks (eCW) · Waystar · FinThrive · Insurance payer portals · Microsoft Excel and reporting tools Certifications · Certified Revenue Cycle Representative (CRCR) or willingness to obtain. Success Metrics · Accounts receivable dollars resolved. · Denial overturn percentage. · Appeal success rate. · Reduction in AR aging. · Reimbursement dollars recovered. · Productivity and quality scores. · Compliance with payer filing deadlines. · Accuracy and completeness of account documentation. Physical Demands: Continuously requires sitting, typing, verbal communication. Frequently requires reaching outward, reaching above the shoulder, lifting items weighing 10 pounds or less, pushing/pulling items weighing 10 pounds or less. Infrequently requires pushing/pulling items weighing up to 50 pounds, pushing/pulling items weighing above 50 pounds, lifting items weighing up to 50 pounds, lifting items weighing up to 20 pounds, squatting/kneeling, bending, crawling. bending, and climbing. Work Environment: Person may be exposed to fumes, airborne particles, infectious diseases, blood/bodily fluids, and disease-bearing specimens. The Onyx Group is an Equal Opportunity Employer.