sprinter-health - Denial & Appeal Specialist
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Requirements
• 3+ years of medical billing experience with a focus on denials and appeals • Hands-on experience across Medicaid managed care and Medicare Advantage payers • Proficiency reading and interpreting 835 remittance files and CARC/RARC codes • CMS-1500 and/or UB-04 billing experience • Strong written communication skills for composing appeals • Clearinghouse and RCM platform fluency — experience with leading billing platforms a plus, not required • Working knowledge of ICD-10-CM, CPT, and HCPCS Level II coding • Ability to identify coding errors as denial root causes without needing to escalate to a coder • CPC, CCA, or CCS credential preferred — or equivalent hands-on experience • Experience with home health, preventive care, or value-based care billing • Prior experience in a lean or startup RCM environment where you built process, not just followed it
Responsibilities
• Manage and work denial buckets across multiple payer relationships — pattern-level resolution, not just individual claims • Write and submit clinical and administrative appeals; escalate to peer-to-peer review when appropriate • Analyze 835 remittance files to identify denial reason codes (CO-4, CO-97, CO-16, PR-96, etc.) and trace root causes back to submission or coding errors • Identify coding-driven denial trends — diagnosis-procedure mismatches, missing modifiers, bundling issues — and flag upstream for correction • Build and maintain a denial tracking log with aging, resolution status, and pattern tagging • Surface denial trends to the RCM Manager with actionable recommendations on a weekly cadence • Work cross-functionally with the Revenue Cycle Specialist to close loop on systemic pre-submission and rejection issues feeding into denials
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