Denial Management Specialist

Denial Management Specialist

Department: Corporate – Revenue Cycle Management
Function: Post-Service Denials
Work Setup: Onsite – Bridgetowne, Quezon City
Shift: Night Shift
Employment Type: Full-time

About the Role

We are looking for a Denials and Appeals Specialist to join our Revenue Cycle Management team. This role is responsible for reviewing, researching, and resolving post-service payer denials for clinic and surgical services.

The Specialist will investigate denial reasons, determine the appropriate resolution, and handle activities such as corrected claims, reconsiderations, written appeals, and payer follow-ups. The role will also collaborate with Coding, Revenue Cycle, and other operational teams to address complex denials, identify recurring issues, and help reduce preventable revenue loss.

Key Responsibilities

• Review, research, and resolve assigned payer denials for clinic and surgical services.
• Analyze denial reasons, claim history, payer responses, account documentation, and related information to determine the appropriate resolution.
• Prepare and submit corrected claims, reconsiderations, written appeals, and supporting documentation based on payer requirements.
• Conduct timely payer follow-ups and monitor denied claims through final resolution.
• Utilize payer portals, EMR/practice management systems, electronic remittance information, and other healthcare revenue cycle tools.
• Review payer policies, reimbursement guidelines, medical policies, and contractual requirements when evaluating denials.
• Coordinate with the Coding team for denials involving coding, modifiers, bundling, medical necessity, or documentation concerns.
• Coordinate with appropriate Revenue Cycle or operational teams for denials related to authorization, eligibility, registration, credentialing, or other upstream processes.
• Identify payer processing errors and pursue appropriate corrected claims, reconsiderations, appeals, or escalations.
• Maintain accurate and complete documentation of denial research, payer communications, actions taken, and resolution details.
• Monitor assigned work queues and outstanding accounts to ensure timely follow-up within payer filing and appeal deadlines.
• Prioritize denial accounts based on deadlines, account value, denial type, and established department guidelines.
• Identify recurring denial trends and communicate findings to leadership to support denial prevention and process improvement.
• Maintain confidentiality of patient, financial, and protected health information in accordance with applicable policies and regulations.

Qualifications

• At least 3 years of experience in healthcare Revenue Cycle Management, medical billing, insurance follow-up, accounts receivable, denial management, or a related healthcare revenue cycle function.
• Direct experience in researching and resolving insurance/payer denials.
• Experience handling corrected claims, reconsiderations, written appeals, and payer follow-ups.
• Knowledge of claim processing, payer adjudication, denial reasons, and healthcare reimbursement processes.
• Experience using an EMR, practice management, patient accounting, or similar healthcare system.
• Strong analytical, research, documentation, and problem-solving skills.
• Ability to manage multiple accounts and meet productivity, quality, and turnaround-time expectations.
• Strong communication and coordination skills.
• High attention to detail and ability to work independently in a fast-paced environment.

Preferred Qualifications

• Experience in orthopedic, surgical, or physician practice billing.
• Experience working in a high-volume healthcare or ambulatory environment.
• Familiarity with athenaOne, EPIC or comparable practice management/patient accounting systems.
• Experience handling commercial insurance, Medicare, Medicaid, Medicare Advantage, and other healthcare payers.
• Medical billing, coding, or Revenue Cycle certification is an advantage.

Work Arrangement

• Work Location: Bridgetowne, Quezon City
• Work Setup: Onsite
• Shift: Night Shift
• Department: Corporate – Revenue Cycle Management