Clinical Appeals Specialist

Clinical Appeals Specialist Independent Living Systems - 2.8 Miami, FL Job Details Full-time 1 day ago Qualifications Collaborate with healthcare professionals Appeals Nursing Electronic health records (EHR) management Medical coding Healthcare Administration Insurance claim appeals processing Regulatory compliance in claims processing HIPAA Master's degree in nursing Mid-level Master's degree Certified Professional Coder CMS regulatory compliance Bachelor's degree Certified Coding Specialist Centers for Medicare and Medicaid Services (CMS) Clinical documentation Medical billing Medical insurance appeals management Bachelor's degree in healthcare administration Bachelor's degree in nursing Patient interaction Master's degree in healthcare administration Claims documentation management Medical terminology 2 years Communication skills Full Job Description We are seeking a Clinical Appeals Specialist to join our team at Independent Living Systems (ILS). ILS, along with its affiliated health plans known as Florida Community Care and Florida Complete Care, is committed to promoting a higher quality of life and maximizing independence for all vulnerable populations. About the

Role:

The Clinical Appeals Specialist plays a critical role in the healthcare services industry by managing and resolving clinical appeals related to insurance claims and patient care. This position ensures that appeals are thoroughly reviewed, accurately documented, and effectively communicated to insurance providers, healthcare professionals, and patients. The specialist collaborates closely with clinical teams to gather necessary medical information and supports the appeals process by interpreting clinical guidelines and insurance policies. The ultimate goal is to facilitate timely and favorable resolutions that uphold patient rights and optimize reimbursement for healthcare services. This role requires a detail-oriented professional who can navigate complex regulatory environments while maintaining a patient-centered approach.

Minimum Qualifications:

Bachelor's degree in Health Administration, Nursing, or a related healthcare field. Minimum of 2 years experience in clinical appeals, medical billing, or healthcare claims processing. Strong understanding of medical terminology, clinical documentation, and insurance claim procedures. Proficiency with electronic health records (EHR) systems and claims management software. Excellent written and verbal communication capabilities. Relevant experience may substitute for the educational requirement on a year-for-year basis.

Preferred Qualifications:

Master's degree in Health Administration, Nursing, or a related healthcare field. Certification in Medical Coding (e.g., CPC, CCS) or Healthcare Compliance. Experience working within a health insurance company or healthcare provider setting. Familiarity with regulatory standards such as HIPAA and CMS guidelines. Advanced knowledge of clinical guidelines and payer policies related to appeals. Demonstrated ability to manage multiple appeals simultaneously in a fast-paced environment.

Responsibilities:

Review and analyze denied or disputed clinical claims to determine the validity and grounds for appeal. Gather and organize relevant clinical documentation, including medical records and physician notes, to support the appeals process. Prepare and submit comprehensive appeal letters and supporting documentation to insurance companies and other payers. Communicate effectively with healthcare providers, insurance representatives, and patients to clarify appeal status and resolve issues. Maintain accurate records of all appeals activities and track outcomes to ensure compliance with regulatory requirements and internal policies. Stay current with changes in healthcare regulations, insurance policies, and clinical guidelines that impact the appeals process. Collaborate with clinical and administrative teams to improve processes and reduce the frequency of claim denials.