Clinical Appeal Specialist

White Rock Medical Center•Dallas, TX

About The Position

The Clinical Appeal Specialist reviews medical records, analyzes insurance denials, and prepares clear, evidence-based clinical and administrative appeals to support appropriate reimbursement for hospital services. The role evaluates clinical documentation, medical necessity, level of care, payer policies, and applicable regulatory requirements in appeals involving denied inpatient, outpatient, and observation claims. The specialist collaborates with Case Management, Utilization Review, Health Information Management (HIM), Medical Coding, and Revenue Cycle teams to identify supporting evidence, meet appeal deadlines, reduce preventable denials, and improve reimbursement outcomes. The position also tracks appeal submissions, payer correspondence, deadlines, and outcomes; maintains records of appeal activity and denial trends; supports escalated and external review processes; and recommends improvements to documentation and denial-prevention processes. The specialist must protect confidential health information and comply with HIPAA requirements, organizational policies, and regulatory standards. The role includes other duties as assigned and expectations for professional communication, customer service, collaboration, and compliance with hospital safety and emergency procedures.

Requirements

Minimum of 2 years of experience in healthcare; experience in clinical appeals, utilization review, denial management, case management, medical coding, or hospital revenue cycle is preferred.
Excellent written and verbal communication skills.
Follow HIPAA guidelines, patient-rights policy, and the compliance program.
Demonstrate knowledge of disaster response, fire and fire-drill procedures, and hospital emergency codes.
Demonstrate working knowledge of the hospital's Life Safety, Utilities Management, Hazardous Materials, Emergency Preparedness, Safety Management, Medical Equipment Management, and Security Management programs.

Nice To Haves

Experience reviewing medical records and interpreting clinical documentation.
Previous experience writing medical-necessity appeals or responding to insurance denials.
Experience with inpatient, outpatient, and observation claims.
Associate's or bachelor's degree in Nursing, Health Information Management, Healthcare Administration, or a related field; an equivalent combination of relevant clinical, coding, utilization review, or healthcare revenue cycle experience may be considered.

Responsibilities

Review electronic medical records, physician documentation, diagnostic results, treatment plans, and other clinical records to support medical-necessity and level-of-care appeals.
Analyze claim denials and identify the reasons for adverse payer determinations.
Research payer policies, contractual requirements, Medicare and Medicaid guidelines, and applicable regulatory standards.
Prepare accurate, well-organized, persuasive appeal letters for commercial insurance, Medicare, Medicaid, and other applicable payers.
Incorporate relevant clinical evidence, treatment timelines, physician findings, and applicable clinical criteria into appeal narratives.
Collaborate with Case Management, Utilization Review, HIM, Medical Coding, Revenue Cycle, and other departments to obtain supporting documentation and clarify discrepancies.
Track appeal submissions, payer correspondence, response deadlines, and appeal outcomes to ensure timely follow-up.
Maintain accurate records of appeal activity, denial trends, and reimbursement outcomes.
Assist with escalated appeals and prepare supporting documentation for external reviews, administrative hearings, or higher-level appeal processes as needed.
Identify recurring denial patterns and recommend opportunities to improve documentation, processes, and denial prevention.
Maintain confidentiality of protected health information and comply with applicable HIPAA requirements, organizational policies, and regulatory standards.
Perform other duties as assigned.
Provide consistent, responsive customer service; express appreciation; use AIDET principles; and maintain a positive attitude.
Communicate professionally, meet deadlines, follow dress code and identification requirements, act ethically, and maintain effective relationships with customers and coworkers.
Attend staff meetings, follow patient-rights and compliance policies, understand the role in disasters and emergency codes, and follow standard precautions and hospital safety procedures.