Clinical Appeals Specialist

This is a fully remote position, open to applicants in United States.

📋 Description

• Assess medical records, denial letters, payer rationales, and supporting documents to ascertain if cases warrant appeals.

• Analyze medical necessity and clinical validation utilizing approved criteria, policies, clinical evidence, and coding guidelines.

• Craft clear, patient-specific appeal letters following approved templates.

• Connect documented clinical facts and evidence to the rationale for each appeal.

• Utilize InterQual, MCG, the Pinson & Tang CDI Pocket Guide, encoding and grouping software, and AHA Coding Clinic guidance.

• Adhere to client priorities, escalation pathways, turnaround times, and workflows.

• Record appeal activities, statuses, actions, and outcomes in the tracking system.

• Collaborate with utilization review, CDI, coding teams, physicians, and revenue cycle stakeholders.

• Achieve quality, productivity, and timeliness standards.

• Identify denial trends, payer patterns, and documentation gaps, and escalate findings accordingly.

• Maintain a secure remote work environment for the protection of health information.

• Adhere to HIPAA regulations, client security requirements, and Sage Clinical RCM confidentiality and information-security policies.

⛳️ Requirements

• Current RN, MD, or DO credential is required.

• Three to five years of experience in utilization review, clinical documentation integrity, coding, or related medical necessity or clinical validation roles.

• Strong clinical reasoning skills and the ability to synthesize complex medical record information into compelling written appeals.

• Familiarity with healthcare reimbursement, payer denials, documentation standards, and the relationship between clinical findings and coded data.

• Excellent professional writing, critical-thinking, organizational, and communication skills.

• Capability to work independently in a remote environment while adhering to client-directed priorities and workflows.

• Reliable internet access and the ability to securely log into client systems.

• Availability as per the agreed-upon work schedule.

• Willingness to engage in virtual meetings, training sessions, and workflow updates.

• Experience in direct appeal letter preparation is preferred.

• Previous experience in a hospital or acute-care revenue cycle setting is preferred.

• Familiarity with InterQual, MCG, encoder or grouping software, AHA Coding Clinic, or similar resources is preferred.

• Experience in documenting appeal outcomes and recognizing denial patterns is preferred.

🏝️ Benefits

• Opportunity for remote work.

• Participation in virtual meetings and training sessions.

• Access to workflow updates and professional development through training.