AR Analyst - Denial Management

AR Analyst - Denial ManagementHospital Billing | Revenue Cycle Operations- Department - Revenue Cycle Management - Reports To - Revenue Cycle Manager / Director - Employment Type - Full-Time - Experience- 2–5 Years (Mid-Level) - Work Location- Flexible (Remote / On-Site / Hybrid) - Client Segment- Hospital Billing - FLSA Status Non- Exempt / Exempt (commensurate with role level)Position SummaryThe AR Analyst - Denial Management is a mid-level revenue cycle professional responsible for the systematic identification, analysis, appeal, and resolution of denied and underpaid claims across hospital billing client accounts. This individual will serve as a critical link between clinical operations, payer relations, and revenue optimization - ensuring maximum reimbursement for our clients through proactive denial prevention and aggressive, compliant claim recovery.Key ResponsibilitiesDenial Management & AR Follow-Up• Manage and work a dedicated AR denial work queue for assigned hospital billing client accounts, focusing on timely resolution within payer timely filing limits.• Analyze Explanation of Benefits (EOBs) and Electronic Remittance Advices (ERAs) to identify root causes of claim denials including medical necessity, authorization, coding, eligibility, and timely filing denials.• Initiate and track first-level and second-level payer appeals with accurate, well-documented supporting clinical and coding rationale.• Contact payer provider relations lines to resolve claims via phone, web portal, or written correspondence.• Identify trends in denial patterns across payers and service lines and escalate findings to the Denial Management Lead or RCM Manager.• Maintain denial resolution productivity metrics consistent with departmental benchmarks (e.g., touches per day, AR days, clean claim rate, denial rate by payer).Coding & Clinical Documentation Review• Collaborate with certified coders to review coding-related denials involving ICD-10-CM/PCS, CPT, and HCPCS Level II codes.• Identify NCCI (National Correct Coding Initiative) edit conflicts, modifier disputes, and bundling issues impacting reimbursement.• Flag documentation gaps or inconsistencies that are triggering medical necessity denials and communicate findings to the clinical documentation improvement (CDI) team.• Apply appropriate modifiers (e.g., -59, -25, -57, -76, -91) to support claims during the appeals process.Payer Contract & Policy Research• Research Medicare, Medicaid, and commercial payer policies (LCDs, NCDs, payer-specific medical policies) to build evidence-based appeal arguments.• Access and utilize payer portals (Navicure, Availity, Change Healthcare, payer-direct portals) to verify claims status and submit appeals.• Stay current with CMS transmittals, payer contract updates, and OIG guidance relevant to hospital billing.Reporting & Analytics• Generate and review denial management reports from the practice management / billing system (e.g., Epic, Cerner, Meditech, Athenahealth, or equivalent).• Provide weekly and monthly AR aging reports to the client and internal management team highlighting denial rate, appeal success rate, and net collections by payer.• Participate in client-facing performance review meetings to present denial trend data and remediation strategies.Compliance & Quality Assurance• Ensure all billing, appeal, and AR follow-up activities comply with HIPAA/HITECH, CMS guidelines, OIG fraud, waste, and abuse (FWA) standards.• Participate in internal audit reviews and self-audits of worked accounts to ensure accuracy and compliance.• Identify and immediately escalate any potential compliance risks, overpayment scenarios, or unusual payer behavior.Required Qualifications• 2–5 years of hands-on AR and denial management experience in a hospital billing or health system revenue cycle environment.• Demonstrated knowledge of UB-04 claim form, hospital revenue codes, occurrence codes, and condition codes.• Proficiency with ICD-10-CM, ICD-10-PCS, CPT, and HCPCS Level II coding in a hospital billing context.• Working knowledge of Medicare and Medicaid reimbursement methodologies (MS-DRG, APC, OPPS, IPPS).• Experience navigating commercial payer portals and submitting electronic and written appeals.• Strong understanding of payer EOB/ERA interpretation and denial remark codes (CARC/RARC).• Proficiency in at least one hospital practice management or billing system (Epic, Cerner, Meditech, CPSI, or equivalent).• Solid understanding of NCCI edits, global surgery rules, and modifier application.• Excellent written and verbal communication skills for payer and client correspondence.Preferred Qualifications• CPC, CCS, RHIT, CRC, or CRCR certification (active or in pursuit).• Experience working in a billing company, MSO, or multi-client RCM environment.• Exposure to risk adjustment, value-based care, or MIPS quality reporting.• Familiarity with RPA/automation tools in denial management workflows.• Experience with Availity, Waystar / Navicure, or Change Healthcare clearinghouse platforms.• Bilingual proficiency (Spanish/English) is a plus.Performance Metrics & BenchmarksKPI / Metric Target BenchmarkDenial Rate (by claim volume)AR Days Outstanding (net)Appeal Overturn Rate > 60% first-level appeal successClaim Touches Per Day 40–70 accounts (complexity-adjusted)Timely Filing Compliance 100% - zero write-offs for TFL90+ Day AR BucketClean Claim Rate > 95% on initial submissionCore Competencies• Analytical Thinking• Ability to identify systemic denial patterns and translate data into actionable insights.• Attention to Detail• High accuracy in coding review, appeal documentation, and compliance adherence.• Client Service Orientation• Professional and proactive communication with hospital clients.• Self-Direction• Ability to manage a personal work queue with minimal supervision and meet deadlines.• Cross-Functional Collaboration• Partners effectively with coders, CDI specialists, client liaisons, and IT.• Regulatory Awareness• Stays current with CMS, OIG, and commercial payer policy updates.Working Conditions• Standard business hours with flexibility based on client time zone requirements.• This role may be performed remotely or on-site or in a hybrid capacity based on client contract requirements and organizational policy.

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