Complex Revenue Recovery Specialist

Description

Working as an advanced individual contributor and escalation resource, the Complex Revenue Recovery Specialist performs detailed claim and payment audits, interprets payer contracts and fee schedules, quantifies financial exposure and recovery opportunities, develops strategic resolution approaches, and coordinates complex escalations with Legal, Compliance, payer relations, operational leaders, and executive stakeholders when appropriate. The position directly supports revenue protection by resolving high-risk reimbursement issues and identifying systemic opportunities to prevent recurrence.

Working as an advanced individual contributor and escalation resource, the Complex Revenue Recovery Specialist performs detailed claim and payment audits, interprets payer contracts and fee schedules, quantifies financial exposure and recovery opportunities, develops strategic resolution approaches, and coordinates complex escalations with Legal, Compliance, payer relations, operational leaders, and executive stakeholders when appropriate. The position directly supports revenue protection by resolving high-risk reimbursement issues and identifying systemic opportunities to prevent recurrence.

• Advanced Revenue Recovery
  - Applies deep reimbursement expertise to resolve high-dollar, escalated, and financially significant payer disputes.
• Financial Investigation
  - Performs detailed claim, payment, and reimbursement analysis to identify variances, exposure, and recovery opportunities.
• Contract Interpretation
  - Interprets payer contracts, fee schedules, reimbursement methodologies, and payment terms to support dispute resolution.
• Appeals & Escalation Strategy
  - Develops advanced appeal, redetermination, reconsideration, ALJ, and payer-escalation strategies.
• Strategic Resolution
  - Evaluates complex fact patterns and develops practical, financially sound approaches to reimbursement disputes.
• Revenue Optimization
  - Identifies opportunities to recover underpayments, prevent revenue leakage, and strengthen future reimbursement outcomes.
• Advanced Problem Solving
  - Uses critical thinking, research, and sound judgment to resolve ambiguous or non-routine reimbursement matters.
• Cross-Functional Influence
  - Coordinates effectively with Revenue Integrity, Legal, Compliance, payer relations, operational leaders, and executive stakeholders.

• Investigate and resolve high-dollar reimbursement discrepancies, complex denials, underpayments, and payment variances.
• Manage escalated payer disputes that require advanced research, documentation, negotiation, or cross-functional intervention.
• Develop and execute recovery strategies for financially significant claims and reimbursement matters.
• Interpret payer contractual obligations, fee schedules, reimbursement methodologies, and applicable payment terms.
• Maintain clear documentation of investigation findings, actions taken, payer responses, and resolution outcomes.

• Develop and support advanced payer appeals and escalation packages using claim history, documentation, contractual terms, and reimbursement requirements.
• Manage Medicare redetermination and reconsideration activities and support Administrative Law Judge (ALJ) matters as applicable.
• Evaluate appeal viability, financial impact, filing requirements, deadlines, and supporting evidence before escalation.
• Track complex appeal and dispute outcomes and identify recurring payer behaviors or reimbursement risks.
• Escalate payer compliance or reimbursement concerns when standard recovery channels have been exhausted.

• Perform detailed claim, payment,…