Patient Financial Services - Medical Appeals Specialist FT

JOB TITLE: PATIENT FINANCIAL SERVICES APPEALS SPECIALIST
DEPARTMENT:   PATIENT FINANCIAL SERVICES

HOURS & SHIFT REQUIREMENTS: Regular full time, 40 hours weekly, Monday thru Friday, 8 – 4:30.

GENERAL SUMMARY
The PFS Medical Appeals Specialist reviews patient medical records and clinical documentation to determine medical necessity and identify the basis for denied claims. The Specialist prepares formal, well-supported appeals and submits clinical documentation to maximize reimbursement while ensuring compliance with payer regulations and organizational policies. This position works with providers, nurses, paramedics, and other healthcare professionals to obtain supporting documentation for claims related to hospital, clinic, and ambulance services.
The role requires strong knowledge of medical terminology, clinical procedures, medical billing and coding, insurance guidelines, and the ability to analyze clinical information and communicate findings effectively.

GIBSON AREA HOSPITAL & HEALTH SERVICES MISSION STATEMENT
To provide personalized, professional healthcare services to the residents of the Communities 
we serve.

PRINCIPLE DUTIES AND RESPONSIBILITIES
1.    Review patient medical records, clinical documentation, and patient care reports to determine medical necessity and support appeals.
2.    Review denied claims and identify the clinical and/or administrative basis for denial.
3.    Research payer policies, medical necessity guidelines, and coverage requirements.
4.    Prepare clear, thorough, and evidence-based appeal letters to maximize appropriate reimbursement.
5.    Select and submit complete medical records and supporting documentation with each appeal.
6.    Work with physicians, nurses, paramedics, and other clinical staff to obtain additional documentation or clarification.
7.    Review appeals for hospital, clinic, and ambulance services.
8.    Submit accurate and complete appeals within required payer deadlines.
9.    Follow up with insurance payers and monitor appeals through final resolution.
10.    Maintain accurate appeal records, documentation, and outcomes.
11.    Track reimbursement recovered and identify recurring denial trends and documentation issues.
12.    Communicate trends and opportunities for improvement to PFS and clinical leadership.
13.    Maintain current knowledge of Medicare, Medicaid, commercial payer requirements, and applicable clinical guidelines.
14.    Maintain patient confidentiality and comply with HIPAA and organizational policies.
15.    Demonstrate strong clinical judgment, critical thinking, attention to detail, and effective written and verbal communication.
16.    Maintain established productivity, quality, timeliness, and accuracy standards

PHYSICAL REQUIREMENTS
1.    Works requires the ability to lift and carry boxes weighing between 5 to 25 pounds.
2.    Physical strength to perform the following lifting tasks:
a.    Floor to Knuckle- 20 pounds
b.    12” to Knuckle- 30 pounds
c.    Knuckle to Shoulder- 20 pounds
d.    Shoulder to Overhead- 10 pounds
e.    Carry 14ft.- 20 pounds
f.    Push 25ft.- 10 ft/lbs
g.    Pull 10 ft.- 10 ft/lbs
3.    Work required ability to stand up for fifteen minutes at a time.
4.    Work requires communication abilities necessary to gather and exchange information with all departments, including the ability to use a telephone.
5.    Work requires ability to use a computer.
6.    Work requires visual acuity necessary to observe and obtain information and use documentation.
7.    Auditory acuity to hear patient/family/others for purposes of communication.

REPORTING RELATIONSHIP
Reports to Director of Patient Financial Services and/or Director of Operations & Revenue Services.
 

Qualifications

EDUCATION, KNOWLEDGE AND ABILITIES REQUIRED:
1.    High School Diploma, GED, or Equivalent work experience.
2.    Clinical healthcare experience required 
3.    Current or previous RN, LPN, Paramedic, EMT, or other clinical healthcare experience preferred
4.    Experience reviewing medical records and clinical documentation preferred.
5.    Experience with medical appeals, medical necessity review, billing, coding, or insurance requirements preferred. Familiar with the Legal and Ethical Compliance in charging and billing.
6.    Knowledge of: CPT, ICD-10-CM, HCPCS, Medical terminology, Medicare and Medicaid regulations and Commercial insurance guidelines
7.    Experience with electronic medical records (EMR/EHR) and billing software.
8.    Strong understanding of payer appeal processes.
9.    Excellent written communication skills.

ADDITIONAL PREFERRED CERTIFICATIONS
1.    Certified Professional Coder (CPC)
2.    Certified Coding Specialist (CCS)
3.    Certified Professional Biller (CPB)
4.    Certified Revenue Cycle Representative (CRCR)

COMPENTENCIES
1.    Revenue Cycle Knowledge: Understanding of the Revenue Cycle process including claims, payment posting, accounts receivable, denial management, and reimbursement processes. 
2.    Attention to Detail: Accurately enter demographics, insurance information, adjustments with minimal errors. 
3.    Analytical / Problem-Solving: Ability to investigate and identify application discrepancies and implement corrective actions. 
4.    Productivity & Time Management: Prioritizes workload, meets deadlines, and manages high volumes of applications efficiently. 
5.    Compliance & Confidentiality: Maintains HIPAA compliance and protects patient health information during billing and collections activities. 
6.    Communication Skills: Communicates professionally with patients, providers, insurance carriers, and coworkers. 
7.    Technology Proficiency: Experience with practice management systems, EHR/EMR platforms, clearinghouses, and software such as Microsoft Office/Excel. 
8.    Accountability / Ownership: Takes responsibility for assigned accounts, follows claims through resolution, and escalates issues appropriately.
9.    Team Collaboration: Works effectively with providers, front office staff, billing office staff and leadership to improve reimbursement and workflow efficiency.

INFECTION EXPOSURE RISK LEVEL
Category 3 – No Risk – Your job does not involve exposure to blood, body fluids or tissue.  You do not perform or help in emergency medical care or first aid as part of your job.

WORKING CONDITIONS
1.    Works in a normal office where there are relatively few discomforts due to adverse or hazardous working conditions.  There is some exposure to noise and personal space is limited.
2.    Will work in an office with co-workers where traffic may be constant, subjecting your work to interruption, which can produce stress and fatigue.