Position Overview

The Revenue Recovery Specialist will play a critical role in ensuring accurate reimbursement and recovering lost revenue for outpatient service providers. This position involves interfacing with insurance carriers, analyzing claims data, and drafting appeals to recover underpaid and denied claims. The ideal candidate must have a strong understanding of outpatient reimbursement methodologies, intermediate Excel skills, and the ability to navigate payer processes independently.

Key Responsibilities

Claims Research and Analysis

• Review claims data in pricing software to identify discrepancies between contracted rates and actual payments.
• Research claims variances in outpatient patient accounting systems (e.g., athenahealth, Nextgen)
• Deep-dive into payer contracts and manuals to understand “why” a claim has been underpaid or denied.
• Review claim details, including coding, billing, and insurance information to verify payer payment discrepancies.

Appeals and Follow-Up 

• Communicate with payer representatives via phone, provider portals, written correspondence, etc. to identify claim status, needed documentation, reasoning for underpayment.
• Draft appeals to insurance companies to recover underpaid claims.
• Adhere to payer-specific strategies (e.g., escalation, appeal, obtaining audit reports, requesting claim correction, etc.) to resolve accounts expeditiously.

Trend Identification and Reporting

• Identify trends in workflow and recommend solutions for efficiency improvements.
• Prepare monthly recovery reporting for the Client.
• Communicate trends during team meetings.

Skills and Knowledge

• Strong understanding of outpatient reimbursement methodologies (e.g., how Medicare reimbursement works, how to calculate reimbursement using a fee schedule, how payment adjustments work).
• Intermediate Excel skills, including pivot tables and large dataset analysis.
• Excellent written and verbal communication skills for professional interactions with payer representatives.
• Demonstrated ability to work autonomously and communicate findings to teammates.
• Persistent problem-solving skills to overcome payer challenges.

Education and Experience

• Required: Minimum 3–5 years of experience in one or more of the following areas:
• Revenue cycle accounts receivable follow-up
• Managed care contracting analysis
• Insurance company claims or payer relations
• Revenue cycle outsourcing recovery
• Associate degree preferred; equivalent work experience accepted.