Clinical Appeal Specialist
Core
Manage healthcare denials, appeals, and reimbursement recovery processes within a complex clinical environment.
Role type
Clinical Appeal Specialist
Builds
Accurate medical claims review and appropriate reimbursement aligned with healthcare regulations and payer requirements
Domain
Healthcare / Revenue Cycle Management
Required skills
Healthcare reimbursement, Medical coding, Insurance policies, Medicare/Medicaid knowledge, Commercial insurance, Managed care requirements, Claims adjudication, Billing compliance, Denial trend analysis, Root cause analysis
Preferred skills
Clinical knowledge, Analytical thinking, Attention to detail
Responsibilities
Coordinate and administer end-to-end denials review and appeals management processes; Review denied healthcare claims, investigate reimbursement issues, and identify opportunities for successful appeals and financial recovery; Analyze payer policies, reimbursement methodologies, regulatory requirements, and administrative rules to determine appropriate appeal strategies; Evaluate medical documentation, billing information, and coding accuracy to support claims adjudication and reimbursement compliance; Apply knowledge of Medicare, Medicaid, commercial insurance, and managed care requirements when reviewing claims and resolving reimbursement disputes; Identify recurring denial patterns, investigate underlying causes, and recommend corrective actions to improve reimbursement processes and operational efficiency; Monitor reimbursement practices and ensure compliance with applicable healthcare regulations, billing requirements, and coding guidelines.