CLINICAL APPEALS SPECIALIST

PRIORITY MANAGEMENT•Dallas, TX

2d•Remote

About The Position

The Clinical Appeals Specialist conducts comprehensive clinical reviews and produces supporting medical records in response to Medicare, Medicaid, and insurance audits and appeals; risk adjustment and quality reviews; and legal or personal medical-record requests. The role follows current federal and state guidelines and the company’s privacy policies and procedures. It requires clinical and regulatory judgment, effective management of deadline-driven work, and the ability to work independently in a remote setting. The specialist reviews and synthesizes handwritten and electronic medical records, develops evidence-based appeal arguments, and may participate in appeal hearings by providing testimony. The position also requires safeguarding protected health information and access credentials, reporting suspected privacy or system-access violations, complying with HIPAA, attending required training, and responding appropriately to behavioral, medical, and fire-safety situations.

Requirements

Experience with documentation requirements for skilled rehabilitation and skilled nursing services, Minimum Data Set (MDS) coding, and/or medical necessity reviews and appeals in skilled nursing or post-acute care settings.
Working knowledge of regulatory and payer reimbursement requirements and reasons for Medicare, Medicare Advantage, or Medicaid claim denials.
Completion of continuing education in case management, regulatory requirements, restorative nursing, medical record documentation, legal aspects of documentation, reimbursement, and compliance.
Working knowledge of ICD-10, CPT, HCPCs, and MDS item coding for PPS/PDPM and OBRA assessments.
Proficiency in Medicare rules and regulations, including coverage, benefit periods, certification, qualification criteria, and the 30-day rule.
Proficiency with Microsoft 365 applications, including SharePoint, Teams, Lists, Excel, and Word; PDF editing software; and database systems.
Strong analytical, written and verbal communication, time-management, independent-work, quality-control, problem-solving, dependability, integrity, and organizational-support skills.
Ability to prioritize competing assignments, meet strict audit and appeal deadlines, and work independently in a remote setting.
Ability to synthesize complex information, communicate clearly, edit written work for spelling and grammar, and adapt writing to the audience and purpose.
Ability to follow policies and procedures, complete administrative tasks correctly and on time, and support organizational goals and values.

Nice To Haves

Experience with Medicare Parts A and B and managed Medicaid.
Background in therapy documentation and reimbursement review.
Experience preparing Administrative Law Judge (ALJ) appeals, developing clinical arguments, organizing supporting evidence, and providing testimony at appeal hearings.
RAC-CT certification; RAC-CTA certification is a plus.
Experience reviewing clinical records in PointClickCare or a comparable electronic health record (EHR) system.

Responsibilities

Review medical records using clinical and regulatory knowledge to identify required supporting documentation.
Conduct clinical nursing reviews of patient records for compliance with facility practices and procedures, as directed.
Manage tasks flexibly and reprioritize workflows to meet deadlines in a production-oriented setting.
Use critical thinking to identify and resolve issues and provide timely feedback about medical review processes.
Develop appeal arguments using clinical evidence, supporting references, and regulations; participate in appeal hearings and provide testimony as required.
Determine regulatory and clinical support for appeal arguments when pre-existing resources are unavailable.
Review and synthesize information from handwritten and electronic medical records to support claims.
Protect assigned user IDs and passwords and promptly report suspected or known disclosure violations to the Director of Medical Records.
Protect residents’ protected health information and promptly report suspected or known violations to the Director of Medical Records.
Report known or suspected unauthorized attempts to access the facility’s information system to the Director of Medical Records.
Attend and participate in mandatory in-service training programs, workshops, and seminars as approved or delegated.
Ensure full compliance with HIPAA regulations.
Respond appropriately to behavioral, medical, and fire-safety situations.
Perform other duties as assigned.