Denial Management Specialist (Out of Network/ Dispute)

Denials & Dispute Management

•         Work a queue of denied claims and payer disputes end to end, including first- and second-level appeals, External Review (IRO) submissions, and regulatory complaints, across Medicare Advantage and Commercial plans.

•         Evaluate claim denials, payer policies, and plan types to determine the appropriate resolution pathway, including appeals, External Review, regulatory complaints, or write-offs when options are exhausted.

•         Complete and submit appeal letters using the provided templates, ensuring each includes the correct patient, claim, payer, and supporting documentation details for the case.

•         Prepare and submit External Review requests using established workflows, ensuring compliance with state, federal, and plan-specific requirements, timelines, and routing rules.

•         Follow up with payers and external review organizations on case status, and escalate cases that are stalled, misrouted, ineligible for the planned pathway, or at risk of missing a deadline.

•         Accurately document all case activity, outcomes, and payer communications in the billing system and tracking tools.

Payer Policy & Compliance

•         Stay current on payer policy, coverage criteria, and billing and coding changes. Use payer policies, routing guides, and state and federal requirements to confirm timelines, eligibility, and submission requirements.

•         Follow established workflows and SOPs, and recommend updates when process gaps are identified.

Trend Identification & Collaboration

•         Track outcomes of appeals, External Reviews, and negotiated claims, and identify denial patterns by payer, line of business, denial category, and code.

•         Report recurring denial trends and root causes to management so process improvements can be made.

•         Work with billing, coding, clinical, and other internal teams to obtain documentation and resolve issues that affect appeal outcomes.

Required Qualifications

•         Bachelor's degree in a healthcare-related field, or 4+ years of directly related equivalent experience.

•         3+ years of experience in medical billing, collections, or accounts receivable follow-up, including experience working denials and appeals and familiarity with prior authorization requirements.

•         Working knowledge of CPT/HCPCS, ICD-10, modifier selection, and UB revenue codes.

•         Proficiency with medical billing systems and G-Suite, plus strong knowledge of medical terminology and healthcare systems.

•         Ability to meet in-office requirements at [location].

Preferred Qualifications

•         Hands-on experience with External Review processes for both Medicare Advantage and Commercial lines of business.

•         Experience with Medicare Advantage appeals processes, including plan-level reconsiderations, IRE/Maximus escalation, and CMS complaint pathways.

•         Familiarity with state External Review and Department of Insurance complaint processes, and with ERISA and state-regulated plan distinctions.

•         Experience in laboratory, molecular diagnostics, or other specialty billing environments.

Skills & Abilities

•         Strong written and verbal communication, including clear, professional communication with payers and internal teams.

•         Strong critical thinking skills, with the ability to review each case on its facts, interpret payer policy and routing rules, and decide the appropriate next step rather than applying a one-size-fits-all process.

•         Sound judgment to recognize when a case falls outside the standard workflow and to escalate appropriately.

•         Ability to meet productivity and quality standards in a deadline-driven, high-volume environment.

•         Ability to balance competing priorities and manage multiple deadline-driven cases.

•         Ability to identify and clearly communicate denial trends.

•         Organized, detail-oriented, and a strong team player.

•         Maintains confidentiality of sensitive and PHI-related information.

Credence Global Solutions (“CGS”) is a Richardson, Texas based diversified technology driven financial transformation company with deep expertise in receivables management and voice based BPO. With focus on Receivables Management, Healthcare RCM, Technology Platforms and Contact Center verticals, CGS services leading telecommunication, healthcare, and media companies.

Healthcare providers serviced by CGS include medical transport providers, emergency physicians, health infusion service providers and diagnostic laboratories. In the telecommunication vertical, CGS serves four of the top five providers in United States.

Credence Resource Management is the flagship company of the Credence Group.

Our mantra is Excellence Beyond Belief. Challenges, growth opportunities and a passion for the Job enables us to repeatedly deliver excellence to our clients. Our teams are encouraged to continually explore their talents and pursue their interests, giving them the authority to gain knowledge and skills to truly be the expert in their domain. We strive to bring on the best and brightest, as well as to invest in their training and education, making them a seamless extension of your team.

Headquartered in Dallas TX, we have delivery offices in San Jose CA; Natchez MS; Mesa AZ & Pune India. Visit www.credencegs.com to know more about the company.