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Claims Denial & Appeals Specialist  

Req Number SUR-17-00029  
Position Claims Denial & Appeals Specialist  
Full-Time/Part-Time Full-Time  
Exempt/Non-Exempt Non-Exempt  
Location Metro Health OAM Surgery Center  
Open Date 3/9/2018  
Close Date 4/16/2018  

Metro Health OAM ASC is an orthopaedic-focused ambulatory surgery center, serving West Michigan since 2010. Providing care to over 5,000 patients per year, our physicians & staff are experienced in state-of-the-art ambulatory orthopaedic surgical services. A collaborative team environment ensures that our patients receive individualized care in a convenient, cost-effective outpatient setting.


  • The Claims Denial & Appeals Specialist is responsible for maintaining up to date patient account records. Responds to insurance and patient inquiries, whether verbal or written. Analyses and pursues past due insurance and patient payments utilizing accounts receivable reports. Handles insurance claim denials, rejections and resubmission of claims.
  • This position reports to the Business Office Manager and Business Office Lead
  • This position has no direct reports.

Essential Functions and Responsibilities:

  • Review and analyze claim denials in order to perform the appropriate appeals necessary for reimbursement.
  • Receives denied claims and researches appropriate appeal steps
  • Communicates directly with the payor, resubmits denied claims, underpaid claims and claims that are inaccurately processed by auditing accounts to check on proper payments, coding, balances, adjustments, etc. and also using appropriate reports and working queues
  • Tracks and documents all denials by payor, visit type and denial category
  • Identifies, documents, and communicates trends in recurring denials and recommends process improvements or system edits to eliminate future denials
  • Works with the payors to understand specific reasons for denials and preventable measures available to prohibit future denials.
  • Maintaining reconciliation log of all daily receipts posted.
  • Monitoring the payments to assure appropriate reimbursement from the third-party payers and informing the Business Office Manager if payment other than expected.
  • Process patient refunds in a timely manner, submitting refund requests as the time of insurance payment/EOB receipt.
  • Providing financial counseling to customers who present payments at the counter or on the phone and need to arrange an approved payment plan.
  • Coordinating with Business Office Manager in daily and monthly balancing of accounts receivable to general ledger.
  • Reviewing and analyzing any past due amounts using aged accounts receivable reports including both patient and insurance accounts.
  • Assist with team coverage and provide support when needed.
  • Accesses, utilizes and discloses Protected Health Information (PHI) according to department policies and HIPAA regulations.
  • Accesses and updates payer websites for authorizations, eligibility, and claims status. And holds confidential all passwords obtained through the various payer sites.
  • Meets quality and productivity standards and deadlines established by management.
  • Cross training in other Business Office positions.
  • Participates in the QI plan by tracking data in accordance with established indicators.
  • Respects and complies with decisions made by the Administrator, Business Office Manager and/or Clinical Manager.
  • Other duties as assigned.


  • High school diploma, GED, or equivalent education;
  • College Education: 1-2 years preferred or equivalent vocational training.

Specialized knowledge:

  • Excellent written and verbal communication skills
  • Must be computer savvy and proficient in Microsoft Office
  • Knowledge of HIPAA guidelines and requirements
  • Experience with computerized patient accounting systems preferred.
  • Extensive knowledge of third party billing and payment methodologies required.
  • Good oral and written communication skills and knowledge of various computer programs and electronic remittances.
  • Knowledge of CPT, ICD-9/10-CM, HCPCS, and modifiers necessary.
  • Effective interpersonal skills with the ability to maintain a self-directed and professional approach to completing daily duties.

Knowledge, Skills and Abilities:

  • Support the mission, vision, and values of the organization.
  • Treat others and their ideas with respect and dignity.
  • Set a good example for others.
  • Maintain the highest standards of honesty, integrity, and communication.
  • Build group cohesiveness and pride through teamwork.
  • Demonstrate confidence in Metro OAM Surgery Center and its workforce in all areas of the community.
  • Value and promote creativity and a sense of urgency
  • Effective communication and interpersonal skills.
  • Motivated, self-directed, and assumes responsibility for actions.
  • Be a good communicator and listener; be available and visible.
  • Develop yourself to your highest potential.
  • Active participation in Quality Initiatives.
  • Ability to complete required annual employee training.
  • Demonstrates a high level of customer service.
  • Ability to prioritize and multi-task.
  • Ability to communicate effectively both verbally and in writing. Use effective interpersonal skills plus ability to maintain a self-directed, mature, disciplined approach to completing work duties.
  • Must be able to make effective decision and judgments while taking appropriate action in demanding situations.

Motor, sensory and physical requirements:

  • Ability to stand or sit for prolonged periods of time.
  • Manual dexterity required to operate modern office equipment.
  • Employee must have normal or correctible range of hearing and eyesight.
  • This position is mainly sedentary, with frequent handling of files and medical charts, requiring standing, bending, and lifting up to 20 lbs. maximum.

Access to Protected Health Information Related to this Position:

The minimum necessary access to protected health information required to perform the functions of this position is: access to all system files in order to support system.

Position Requirements  
EOE Statement We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, disability status, protected veteran status or any other characteristic protected by law.  

This position is currently not accepting applications.

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