Clinical Appeal Specialist

White Rock Medical Center LLC•Dallas, TX

About The Position

White Rock Medical Center is seeking a Clinical Appeal Specialist to review medical records, analyze insurance denials, and prepare clear, evidence-based clinical and administrative appeals in support of appropriate reimbursement for hospital services. The specialist evaluates clinical documentation, medical necessity, level of care, payer policies, and applicable regulatory requirements, and develops persuasive appeal letters for denied inpatient, outpatient, and observation claims. The position collaborates with Case Management, Utilization Review, Health Information Management (HIM), Medical Coding, Revenue Cycle, and other teams to identify supporting evidence, meet appeal deadlines, reduce preventable denials, and improve reimbursement outcomes. The specialist also tracks appeals and outcomes, supports escalated and external review processes, identifies recurring denial patterns, and maintains confidentiality of protected health information in accordance with HIPAA and organizational policies.

Requirements

At least 2 years of experience in healthcare.
Excellent written and verbal communication skills.
Follow HIPAA guidelines and patient rights policies, and comply with the compliance program.

Nice To Haves

Experience in clinical appeals, utilization review, denial management, case management, medical coding, or hospital revenue cycle.
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 HIPAA requirements, organizational policies, and regulatory standards.
Perform other duties as assigned.
Follow customer service and behavioral standards, including using AIDET principles, responding promptly to requests and questions, maintaining a positive attitude, and treating others respectfully.
Meet communication and workplace standards, including wearing a name tag properly, following the dress code, answering phones promptly, being prepared for meetings, and meeting deadlines.
Attend staff meetings and follow HIPAA guidelines, patient rights policy, and the compliance program.
Demonstrate knowledge of disaster response, fire and fire drill procedures, hospital emergency codes, standard precautions, and applicable environment-of-care safety programs.