Clinical Appeals & Reimbursement Strategist

Riverside Healthcare

Kankakee (IL)

On-site

USD 43,000 - 56,000

Full time

14 days+

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Job summary

Riverside Healthcare in Illinois is seeking a Clinical Appeals Analyst to manage and process clinical appeals and denials, collaborating with providers and revenue cycle teams to secure appropriate reimbursement.

Candidates should have a bachelor's in a health-related field, 3+ years in clinical appeals or utilization management, and proficiency with Epic or similar EHRs and appeals software. The role emphasizes analytical skills, attention to detail, and persuasive written communication.

Qualifications

Bachelor's degree in Nursing, Healthcare Administration, or a related field is required.
3+ years of experience in clinical appeals, utilization management, or revenue cycle operations within a healthcare setting.
Strong knowledge of payer policies, medical necessity criteria, and healthcare reimbursement processes.
Excellent analytical, organizational, and problem-solving skills.
Strong written and verbal communication skills, with the ability to craft persuasive appeal letters.
Proficiency in using appeals management software and electronic health records systems (Epic preferred).
Ability to work independently, prioritize tasks effectively, and maintain attention to detail in a fast-paced environment.

Responsibilities

Review and analyze denied claims to determine the basis for denial and the potential for successful appeal.
Draft and submit clinical appeals to payers, utilizing medical records, clinical documentation, and medical necessity criteria to support the appeal.
Collaborate with medical providers, coding specialists, CDI, and revenue cycle team to gather necessary documentation for clinical appeals.
Perform root cause analysis of denied claims to identify trends and opportunities for process improvement.
Monitor the status of submitted appeals and ensure timely follow-up with payers for resolution.
Maintain a detailed log of appeals activity, including outcomes and any necessary follow-up actions.
Stay up-to-date with payer policies, reimbursement guidelines, and regulatory changes that may impact the appeals process.
Work with insurance representatives to resolve escalated issues and negotiate settlements as necessary.
Develop reports and presentations on appeals activity and outcomes for leadership and relevant stakeholders.
Perform analysis on refund requests for inpatient clinical accounts.