Revenue Cycle Denials Representative

About the Role The Revenue Cycle Denials Representative is responsible for managing and resolving denied PB (CMS-1500) and HB (UB-04) claims. This role identifies root causes of denials, executes appeals and corrective actions, and collaborates with internal teams to prevent future denials.

The ideal candidate has hands-on experience with CARC/RARC denial codes, Epic denial work queues, and payer-specific appeal requirements across Medicare, Medicaid, and commercial payers. What You'll Do

• Denial Review & Resolution – Review and analyze denied PB (CMS-1500 / 837P) and HB (UB-04 / 837I) claims to determine root causes and appropriate resolution strategies.

• Analyze account history and all previous actions in Epic prior to taking the next action step to resolve the claim.

• Work claims across top denial categories including, but not limited to: No Authorization, Timely Filing, Coordination of Benefits (COB), Medical Necessity, Additional Documentation Requests (ADR), Bundling (NCCI edits), and Duplicate Claims.

• Interpret CARC and RARC codes on 835 ERA / EOB remittance data for both PB and HB claims to determine the correct resolution path.

• Understand when claim corrections, rebilling (837P or 837I), or void-and-replace actions are appropriate.

• Escalate claims with payers for resolution when processing is inaccurate or delayed.

• Appeals & Reconsiderations – Prepare and submit appeals and reconsideration requests in compliance with payer-specific guidelines and deadlines for both PB and HB denied claims. Attach appropriate clinical documentation, medical records, authorization references, and justification letters to support appeal submissions. Meet appeal deadlines for Medicare, Medicaid, and commercial payers in accordance with payer-specific requirements.

• Trend Identification & Prevention – Identify denial trends across PB and HB claim types and collaborate with coding, clinical, and billing teams to implement corrective actions. Monitor payer policy and regulatory changes (Medicare LCDs/NCDs, Arkansas Medicaid updates) to proactively prevent denials. Assist in developing best practices and training materials for PB and HB denial management and prevention.

• Payer & System Knowledge – Navigate Epic denial and underpayment work queues for both HB and PB modules; document all denial actions and resolutions. Utilize payer portals (Availity, Arkansas DHS, Medicare.gov, and commercial payer sites) to research denial reasons and submit appeals. Utilize resources provided by the client to promote accuracy and resolve claims in accordance with client expectations.

• Compliance & Documentation – Maintain thorough documentation of denial reasons, appeal actions, and resolutions in Epic. Ensure compliance with federal, state, and payer regulations as well as hospital and physician practice policies. Communicate effectively with insurance representatives and internal leadership. What We're Looking For

• Hands-on experience with CARC/RARC denial codes, Epic denial work queues, and payer-specific appeal requirements across Medicare, Medicaid, and commercial payers.

• Experience reviewing denied PB (CMS-1500 / 837P) and HB (UB-04 / 837I) claims to identify root causes and determine resolution strategies.

• Ability to interpret CARC and RARC codes on 835 ERA/EOB remittance data; knowledge of when corrections, rebilling, or void-and-replace actions are appropriate.

• Familiarity with top denial categories: No Authorization, Timely Filing, COB, Medical Necessity, ADR, NCCI Bundling, and Duplicate Claims.

• Proficiency using Epic denial and underpayment queues and payer portals (Availity, Arkansas DHS, Medicare.gov, commercial payer sites) for research and appeals.

• Strong compliance mindset and documentation skills; ability to maintain clear Epic entries and meet payer deadlines.

• Nice to Have

• Arkansas Medicaid updates and Medicare LCDs/NCDs monitoring experience.

• Training material development and best-practice documentation for denial prevention.

• Experience with 837P/837I rebilling, CEP or higher-level claims denial management.