Clinical Appeal Specialist
J
JobgetherHealthcare reimbursement
Based in the United StatesFull-TimeSenior
Salary31.99 - 48.8 USD per hour
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Job Details
- Experience
- Bachelor's degree combined with at least five years of healthcare experience; or Associate's degree combined with at least seven years of healthcare experience.
- Required Skills
- Microsoft AccessMicrosoft Excel
Requirements
- Have an Associate's degree in Healthcare, Finance, or a related field; alternatively, meet one of the specified degree and experience pathways.
- For the bachelor's pathway, have at least five years of healthcare experience and an active Registered Nurse (RN) license.
- For the associate's pathway, have at least seven years of healthcare experience, preferably in nursing, and an active RN license.
- Hold active RN licensure; current LPNs in Clinical Denial Specialist positions may be eligible for two years to obtain RN licensure.
- Know healthcare reimbursement, benefit investigations, payer reimbursement policies, regulatory requirements, and administrative procedures.
- Understand Medicare, Medicaid, managed care organizations, third-party reimbursement, and insurance payer structures.
- Have experience with hospital and insurance reimbursement processes, medical billing, payment compliance, denials, and appeals.
- Understand reimbursement methodologies including per-diem, DRG, fee schedules, percentage of charges, and stop-loss arrangements.
- Know medical coding systems including ICD, CPT, HCPCS, DRG, APG, APC, and revenue codes.
- Analyze financial data and interpret reimbursement information to identify trends and discrepancies.
- Have intermediate Microsoft Excel skills and familiarity with Microsoft Office applications and Microsoft Access.
- Preferred: experience in oncology nursing or an oncology healthcare environment, utilization review, quality management, or recent case management; experience with Soarian or similar healthcare information and reimbursement systems is also preferred.
Responsibilities
- Coordinate end-to-end denials review and appeals management, including claims recovery and root cause analysis.
- Review denied healthcare claims, investigate reimbursement issues, and identify opportunities for appeals and financial recovery.
- Analyze payer policies, reimbursement methodologies, regulations, and administrative rules to determine appeal strategies.
- Evaluate medical documentation, billing information, and coding accuracy to support claims adjudication and reimbursement compliance.
- Apply Medicare, Medicaid, commercial insurance, and managed care requirements when reviewing claims and resolving reimbursement disputes.
- Identify recurring denial patterns, investigate causes, and recommend corrective actions to improve reimbursement processes.
- Monitor reimbursement practices for compliance with healthcare regulations, billing requirements, and coding guidelines.
- Use financial data and reporting tools to evaluate denial trends and track recovery performance.
- Collaborate with clinical, financial, case management, and other internal stakeholders to resolve reimbursement and appeals issues.
- Maintain accurate documentation, meet assignment timelines, and recommend operational improvements to enhance revenue cycle effectiveness.
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