Sr. Denials & Appeals Specialist

The Sr. Denials & Appeals Specialist will manage complex insurance denials and oversee the appeals process to ensure accurate reimbursement and minimize revenue loss. This role involves analyzing denied claims, identifying trends, and developing strategies to prevent future denials. The Sr. Denials & Appeals Specialist will collaborate with departments including billing, coding, and customer service to resolve issues and optimize the revenue cycle process. This position will require strong knowledge of payer requirements, healthcare billing codes, and a deep understanding of claims management.

KEY RESPONSIBILITIES

·       Oversee and manage the appeals process for denied claims, ensuring timely and accurate submission of appeal documentation according to payer guidelines. Handle complex or high-value denials, consulting with appropriate staff to resolve outstanding issues.

·       Analyze denied claims to identify root causes, trends, and patterns. Work collaboratively with departments to implement corrective actions and prevent recurrence.

·       Work closely with billing, coding, payer relations, and clinical teams to address issues related to denials. Provide guidance on proper coding, documentation, and billing practices.

·       Ensure that all denials and appeals are handled in compliance with applicable regulations and guidelines (e.g., HIPAA), and maintain thorough and accurate documentation.

·       Prepare and submit detailed and timely appeal letters and supporting documentation to payers, following specific payer requirements.

·       Provide training and support to junior denials and appeals specialists on best practices, guidelines, and payer requirements. Foster a collaborative work environment.

·       Track key performance indicators (KPIs) related to the denials and appeals process, including appeal success rates, denial trends, and resolution times. Report findings to senior management.  

Qualifications: 

• College degree preferred or equivalent experience of 5 plus years
• 5 years’ experience in medical billing; strong preference will be given to candidates with molecular laboratory billing experience. Medical billing experience may be substituted for a bachelor’s degree.
• Understanding of patient protections under HIPAA and proper handling of protected health information (PHI).
• Working knowledge of health insurance and terminology.  
• Excellent communication and people skills.
• Meticulous with strong analytical and problem-solving abilities.

Skills: 

• Strong knowledge of insurance guidelines, CPT/ICD-10 codes, and medical terminology.
• Excellent attention to detail and time management skills.
• Effective communication and problem-solving abilities.
• Proficiency in Microsoft Office Suite and healthcare software tools.

EEO STATEMENT

Baylor Genetics is proud to be an equal opportunity employer dedicated to building an inclusive and diverse workforce. We do not discriminate based on race, religion, color, national origin, sex, sexual orientation, age, gender identity, veteran status, disability, genetic information, pregnancy, childbirth, or related medical conditions, or any other status protected under applicable federal, state, or local law. 

Note to Recruiters:  

We value building direct relationships with our candidates and prefer to manage our hiring process internally. While we occasionally partner with select recruitment agencies for specialized roles, we do not accept unsolicited resumes from recruiters or agencies without a written agreement executed by the authorized signatory for Baylor Genetics ("Agreement"). Any resumes submitted to Baylor Genetics in the absence of an Agreement executed by Baylor Genetics' authorized signatory will be considered the property of Baylor Genetics, and Baylor Genetics will not be obligated to pay any associated recruitment fees.