Patient Financial Services - Medical Appeals Specialist FT

GIBSON AREA HOSPITAL•Gibson City, IL

2d•$25 - $34•Onsite

About The Position

The Patient Financial Services Medical Appeals Specialist reviews patient medical records and clinical documentation to determine medical necessity and identify why claims were denied. The Specialist prepares evidence-based appeals and submits supporting clinical documentation to maximize appropriate reimbursement while complying with payer requirements and organizational policies. The role supports appeals for hospital, clinic, and ambulance services and works with providers, nurses, paramedics, and other healthcare professionals to obtain documentation or clarification. It requires knowledge of medical terminology, clinical procedures, medical billing and coding, insurance guidelines, and effective analysis and communication skills. This is a regular full-time position of 40 hours per week, Monday through Friday, from 8:00 a.m. to 4:30 p.m. It is located at Heartland Bank in Gibson City, Illinois, and reports to the Director of Patient Financial Services and/or the Director of Operations & Revenue Services. The position is performed in a normal office with some noise, limited personal space, and potentially frequent interruptions from coworker traffic. The stated infection exposure risk is Category 3 – No Risk; the job does not involve exposure to blood, body fluids, or tissue, or participation in emergency medical care or first aid. Physical requirements include lifting and carrying items, standing for periods, using a computer and telephone, and having visual and auditory acuity for documentation and communication.

Requirements

High school diploma, GED, or equivalent work experience.
Clinical healthcare experience required.
Knowledge of CPT, ICD-10-CM, HCPCS, and medical terminology.
Knowledge of Medicare and Medicaid regulations and commercial insurance guidelines.
Experience with electronic medical records (EMR/EHR) and billing software.
Strong understanding of payer appeal processes.
Excellent written communication skills.
Understanding of revenue cycle processes, including claims, payment posting, accounts receivable, denial management, and reimbursement.
Ability to investigate discrepancies, identify causes, and implement corrective actions.
Ability to prioritize workload, meet deadlines, and manage high volumes efficiently.
Ability to protect patient health information and maintain HIPAA compliance.
Professional communication skills with patients, providers, insurance carriers, and coworkers.
Technology proficiency with practice management systems, EHR/EMR platforms, clearinghouses, and software such as Microsoft Office/Excel.
Accountability for assigned accounts, following claims through resolution, and escalating issues appropriately.
Ability to collaborate with providers, front office staff, billing office staff, and leadership.
Ability to lift and carry boxes weighing 5 to 25 pounds and perform the listed lifting, carrying, pushing, and pulling tasks.
Ability to stand for up to fifteen minutes at a time.
Ability to use a telephone and computer, and the visual and auditory acuity needed to observe, obtain, and communicate information.

Nice To Haves

Current or previous RN, LPN, Paramedic, EMT, or other clinical healthcare experience.
Experience reviewing medical records and clinical documentation.
Experience with medical appeals, medical necessity review, billing, coding, or insurance requirements.
Familiarity with legal and ethical compliance in charging and billing.
Certified Professional Coder (CPC).
Certified Coding Specialist (CCS).
Certified Professional Biller (CPB).
Certified Revenue Cycle Representative (CRCR).

Responsibilities

Review patient medical records, clinical documentation, and patient care reports to determine medical necessity and support appeals.
Review denied claims and identify the clinical and/or administrative basis for denial.
Research payer policies, medical necessity guidelines, and coverage requirements.
Prepare clear, thorough, evidence-based appeal letters to support appropriate reimbursement.
Select and submit complete medical records and supporting documentation with each appeal.
Work with physicians, nurses, paramedics, and other clinical staff to obtain additional documentation or clarification.
Review appeals for hospital, clinic, and ambulance services.
Submit accurate and complete appeals within payer deadlines.
Follow up with insurance payers and monitor appeals through final resolution.
Maintain accurate appeal records, documentation, and outcomes.
Track recovered reimbursement and identify recurring denial trends and documentation issues.
Communicate trends and improvement opportunities to PFS and clinical leadership.
Maintain current knowledge of Medicare, Medicaid, commercial payer requirements, and applicable clinical guidelines.
Maintain patient confidentiality and comply with HIPAA and organizational policies.
Meet established productivity, quality, timeliness, and accuracy standards.