Human Xpert India Private Limited
Website:
humanxpert.com
Job details:
AR Analyst - Denial Management
Hospital 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 Summary
The 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 Responsibilities
Denial 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 & Benchmarks
KPI / Metric Target Benchmark
Denial Rate (by claim volume) < 5% initial denial rate
AR Days Outstanding (net) < 40 days (varies by client)
Appeal Overturn Rate > 60% first-level appeal success
Claim Touches Per Day 40–70 accounts (complexity-adjusted)
Timely Filing Compliance 100% - zero write-offs for TFL
90+ Day AR Bucket < 15% of total AR
Clean Claim Rate > 95% on initial submission
Core 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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