Senior Denials and Appeals Specialists

Senior Denials and Appeals Specialists Clearwater, FL 33760 $25.31 - $32.00 an hour - Full-time $25.31 - $32.00 an hour - Full-time Senior Denials & Appeals Specialist The Senior Denials & Appeals Specialist is a subject-matter expert within the DME revenue cycle, responsible for managing complex claim denials, payer appeals, and reimbursement recovery initiatives. This role serves as a key escalation point for denied claims, ensures compliance with Medicare, Medicaid, and commercial payer requirements, and drives process improvements that reduce write-offs, accelerate cash flow, and support scalable growth. Denials Management & Appeals Oversight Lead resolution of complex denied claims across Medicare, Medicaid, and commercial payers for DME products. Manage high-risk, high-dollar, and exception-based appeals through all levels of the payer review process. Serve as the escalation point for unresolved denials, payer disputes, and reimbursement discrepancies. Analyze denial root causes and coordinate corrective action plans across departments. Documentation, Compliance & Risk Management Ensure appeals and claim submissions comply with Medicare DMEPOS regulations, LCDs, NCDs, and commercial payer policies. Validate completeness and accuracy of clinical documentation, SWOs, CMNs, medical necessity, and supporting records required for appeals. Prepare comprehensive appeal packages including clinical narratives, payer rebuttals, and supporting documentation. Proactively identify compliance risks and implement corrective actions to reduce future denials and audit exposure. Revenue Cycle Leadership & Collaboration Partner with intake, billing, collections, and clinical teams to improve clean claim rates and reimbursement outcomes. Provide guidance and expertise to operational teams regarding denial prevention and payer-specific billing requirements. Support A/R reduction initiatives through timely appeal resolution and denial recovery strategies. Collaborate with leadership to identify trends impacting reimbursement performance. Process Improvement & SOP Ownership Own and maintain SOPs related to denials management, appeals workflows, and payer dispute resolution. Analyze denial trends, payer behavior, and audit activity to improve operational processes and recovery rates. Participate in implementation of workflow enhancements, payer policy updates, and system improvements. Assist in developing denial prevention strategies and operational best practices. Training & Mentorship Serve as a mentor and resource for billing, collections, and appeals staff. Assist in onboarding and training team members on payer policies, appeal strategies, and denial resolution best practices. Provide ongoing education regarding Medicare and commercial payer regulatory changes. Data, Reporting & KPIs Monitor and report on key performance metrics including denial rates, overturn rates, appeal success rates, aging, and reimbursement recovery. Use data analytics to drive accountability, operational efficiency, and continuous improvement. Collaborate with leadership on dashboards, payer trend analysis, and revenue forecasting inputs. Qualifications 5+ years of experience in denials management, appeals, or healthcare revenue cycle within DME or healthcare services. Deep knowledge of Medicare DMEPOS rules, LCDs/NCDs, payer policies, and appeals processes. Proven experience handling complex denials, escalations, audits, and payer disputes. Strong analytical, organizational, writing, and communication skills. Ability to operate independently and lead within a matrixed team environment. CPC, CPB, or DMEPOS-specific certification preferred. Experience supporting audits, ADRs, redeterminations, reconsiderations, and payer reviews preferred. Experience with revenue cycle systems, clearinghouses, payer portals, and denial tracking tools. Prior leadership or team lead experience preferred. Work Location On-site in Clearwater, Florida Job Type Full-time Benefits Flexible schedule Health insurance Paid time off Work Location In person

Pay:

$25.31 - $32.00 per hour

Benefits:

Flexible schedule

Work Location:

In person