PFS - Medical Appeals Specialist FT

GIBSON AREA HOSPITAL•Gibson City, IL

1d•$25 - $34•Onsite

About The Position

The PFS Medical Appeals Specialist is responsible for analyzing patient records, writing formal arguments, preparing, submitting and tracking insurance claims to maximize reimbursement while ensuring compliance with payer regulations and organizational policies. The focus would be on investigating claim errors, matching medical codes to payer rules, and submitting supporting clinical proof for claims related to Hospital, Clinic and Ambulance services. This role requires strong knowledge of medical billing, coding, insurance guidelines, and excellent analytical and communication skills.

Requirements

High School Diploma, GED, or Equivalent.
Minimum of 2 years of experience in medical billing, insurance follow-up, appeals or related field.
Familiar with the Legal and Ethical Compliance in charging and billing.
Knowledge of: CPT, ICD-10-CM, HCPCS, Medical terminology, Medicare and Medicaid regulations, Commercial insurance guidelines.
Experience with electronic medical records (EMR/EHR) and billing software.
Strong understanding of payer appeal processes.
Excellent written communication skills.

Nice To Haves

Certified Professional Coder (CPC)
Certified Coding Specialist (CCS)
Certified Professional Biller (CPB)
Certified Revenue Cycle Representative (CRCR)

Responsibilities

Preparing timely, well-supported appeals for submission to government and commercial payers.
Collaborate with coding, patient accounts, collections, registration, and clinical departments to resolve recurring issues.
Improve reimbursement outcomes while maintaining compliance with payer regulations and organizational policies.
Research payer policies, contracts, medical necessity guidelines, and coverage criteria.
Prepare and submit first-level, second-level, and external appeals within payer deadlines and necessary.
Draft professional appeal letters supported by medical documentation, coding guidelines, payer policies, and regulatory requirements.
Monitor appeal status and follow up with insurance companies until resolution.
Maintain accurate documentation of appeal activity in the billing system.
Escalate complex appeals to leadership when appropriate.
Maintain productivity and quality standards established by the department.
Stay current on payer policy changes, CPT, ICD-10-CM, HCPCS, and regulatory updates.
Other duties as assigned