Clinical Appeals Specialist

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We are hiring for
Clinical Appeals Specialist

What's in it for you?

• Competitive Compensation
• Monthly Allowance & Perfect Attendance Bonus
• Mid-Year Bonus
• HMO Coverage & Life insurance
• Mandated Government Benefits
• 25% Night Differential
• Company provided equipment
• Great Company Culture

Work Set-up:
Site Only

Shift:
08:00 PM - 05:00 AM, Monday – Friday

Roles and Responsibilities:

The Clinical Appeals is responsible for performing audits of medical records on behalf of hospital clients to support denial reviews, defense audits, disallowed charge evaluations, and utilization reviews. This role requires strong clinical judgment, critical thinking skills, and the ability to apply standardized criteria such as InterQual and Milliman (MCG), as well as payer-specific and Medicaid guidelines. The specialist composes detailed appeal letters, ensures compliance with healthcare regulations, and works across multiple systems to manage and resolve complex cases.

• Perform comprehensive audits of medical records to identify or defend charges, including defense audits, patient inquiries, disallowed charges, and biller-requested audits.
• Analyze medical records using standardized criteria (e.g., InterQual, MCG) and payer-specific guidelines (Medicare, Medicaid, commercial insurers) to determine medical necessity and appropriateness of care.
• Review and support appeals related to avoidable length of stay, managed care, RAC audits, and other specialized audit appeals (e.g., CERT, ZPIC, SMRC).
• Request and obtain appropriate supporting documentation from physicians, hospitals, patients, or current medical literature.
• Compose detailed appeal letters addressing both contractual and clinical issues.
• Manage multiple concurrent cases, ensuring prioritization and timely resolution aligned with workflow standards.
• Accurately enter audit findings and documentation into client-based systems.
• Navigate and utilize various electronic systems, including EMRs, billing systems, and quality reporting platforms, to complete assigned tasks efficiently.
• Adhere to departmental policies and procedures, as well as applicable federal and state laws, including HIPAA, FDCPA, and FCRA.
• Ensure the secure and confidential handling of patient information in all aspects of documentation and communication.
• Maintain a strong working knowledge of Medicare, Medicaid, and other payor compliance requirements relevant to the patient population.
• Participate in required training and maintain up-to-date knowledge of regulations, standards, and best practices in clinical auditing and appeals.

Required Qualifications:

• At least three (3) years of clinical experience or equivalent in auditing, Medicare appeals, utilization review, or denials management.
• Experience in medical records review, claims processing, or clinical case management.
• Strong working knowledge of Medicare/Medicaid regulations.
• Proficient in electronic medical records and multiple system navigation.
• Strong analytical and critical thinking skills.
• Meticulous attention to detail and accuracy.
• Able to interpret complex clinical cases and guidelines.
• Proficient in Microsoft Office (Word, Excel, Outlook).
• Customer service-oriented with professionalism, flexibility, and a commitment to continuous learning and excellence

Why choose CONNEXT?

Great Company Culture, Great Place to work Certified, Great Benefits, and lots of room for growth

CONNEXT
is a dedicated team of business process outsourcing experts and innovators, with experience in supporting world-class companies in Title and Escrow, Healthcare, Produce Distribution, Retail and Fashion, Design Consulting, and Finance industries.