Senior Insurance Appeals & Denial Management Specialist at Medical Data Systems – Nashville, Tennessee

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)