CLINICAL APPEALS SPECIALIST

Priority Management; Dallas (TX); Remote; USD 55,000 - 85,000; Full time

Job summary

Priority Management is seeking a Clinical Appeals Specialist to perform comprehensive clinical reviews and prepare supporting medical records for Medicare/Medicaid audits and appeals. The role requires proficiency in MDS coding, HIPAA compliance, and regulatory documentation within a post-acute care setting.

You will develop clinical appeal arguments, synthesize information from EHRs, and coordinate with teams in a remote, production-oriented environment to meet strict deadlines.

Qualifications

• Experience with documentation requirements for skilled rehabilitation and skilled nursing services.
• MDS coding and/or medical necessity reviews and appeals in skilled nursing or post-acute care settings.
• Working knowledge of regulatory and payer reimbursement requirements and reasons for claim denials.

Responsibilities

• Conduct clinical reviews of records to determine required supporting documentation.
• Develop appeal arguments using clinical evidence and regulations; provide testimony as needed.
• Ensure HIPAA compliance and report suspected violations; maintain data accuracy and security.

Skills

HIPAA compliance

MDS coding

Medicare/Medicaid regulations

Data analysis

Communication

Time management

Independent work

Attention to detail

Problem solving

Regulatory documentation

Education

BA/BS in healthcare administration or related field

Case management certification (preferred)

Tools

PointClickCare

Microsoft 365

EHR systems

PDF editing

Job description

JOB SUMMARY:In accordance with current federal and state guidelines as well as in accordance with our company’s established privacy policies and procedures; The Clinical Appeals Specialist is responsible for the comprehensive clinical review and production of supporting medical records in response to Medicare, Medicaid, and Insurance audits/appeals; risk adjustment/quality reviews; and legal/personal medical records requests.ESSENTIAL DUTIES AND RESPONSIBILITIES:Medical records review utilizing clinical and regulatory knowledge to determine required supporting documentationClinical nursing review of patient records for compliance with facility practices and procedures as directedFlexibly manage tasks to meet deadlines by re-prioritizing workflows in a production-oriented settingEmploy critical thinking to identify/resolve issues and provide timely feedback regarding medical review processesDevelop appeal arguments using clinical evidence, supporting references/regulations, and participate in appeal hearings by providing testimony, as requiredDetermine regulatory and clinical support for appeal arguments when pre-existing resources are unavailableProficiently review and synthesize abstract information from handwritten/electronic medical records to support claimsAgree not to disclose assigned user ID code and password for accessing resident/facility information and promptly report suspected or known violations of such disclosure to the Director of Medical Records.Agree not to disclose resident’s protected health information and promptly report suspected or known violations of such disclosure to the Director of Medical Records.Report any known or suspected unauthorized attempt to access facility’s information system to Director of Medical Records.Attend and participate in mandatory in-service training programs, workshops, seminars, etc., as approved / delegated.Ensure full compliance with HIPAA regulationsWorking knowledge of ICD-10, CPT coding, HCPCs, and MDS item coding for PPS/PDPM and OBRA assessmentsProficiency in Medicare rules and regulations including coverage, benefit periods, certification, qualification criteria, 30-day rule, etc.Respond appropriately to behavioral, medical, and fire safety situationsOther duties as assignedSKILLS/COMPETENCIESTechnology – Proficient in Microsoft 365 applications, including SharePoint, Teams, Lists, Excel, and Word; PDF editing software; and database systems to manage and retrieve information, track audit and appeal activity, prepare and submit documentation, and collaborate on shared filesAnalytical - Applies strong analytical skills to synthesize complex or diverse information, using experience and judgment to complement dataCommunication – Demonstrates strong written and verbal communication skills; presents information clearly and accurately; listens, seeks clarification, and responds effectively to questions; delivers group presentations; edits written work for spelling and grammar; adapts writing style to the audience and purposeTime Management and Independent Work – Prioritizes competing assignments, meets strict audit and appeal deadlines, and works independently in a remote settingQuality - Demonstrates accuracy and thoroughness; excellent attention to detail with a critical eye to catch/correct mistakes and errors; applies feedback to improve performance; monitors own work to ensure qualityProblem Solving – Identifies/resolves problems in a timely manner; develops solutions; works well in group problem solving situationsDependability - Follows instructions and responds to management direction; takes responsibility for own actions; keeps commitments and completes tasks on time or notifies appropriate person with an alternate planCharacter - Demonstrates integrity in every aspect of work and dealing with others; consistently models desired behaviors and values established by the company; respects diversity of perspective in discussions and demonstrates an inclusive style; demonstrates concerns for job safety for self and othersOrganizational Support - Follows policies and procedures; completes administrative tasks correctly and on time; supports organization's goals and valuesQUALIFICATIONS/EXPERIENCE:Experience with documentation requirements for skilled rehabilitation and skilled nursing services, Minimum Data Set (MDS) coding, and/or medical necessity reviews and appeals in skilled nursing or post-acute care settings. Working knowledge of regulatory and payer reimbursement requirements and reasons for Medicare, Medicare Advantage, or Medicaid claim denials.Completion of continuing education in case management, regulatory requirements, restorative nursing, medical record documentation, legal aspects of documentation, reimbursement, and compliance.ADDITIONAL PREFERRED QUALIFICATIONS:Experience with Medicare Parts A and B and managed Medicaid.Background in therapy documentation and reimbursement review.Experience preparing Administrative Law Judge (ALJ) appeals, developing clinical arguments, organizing supporting evidence, and providing testimony at appeal hearings.RAC-CT certification; RAC-CTA certification is a plus.Experience reviewing clinical records in PointClickCare or a comparable electronic health record (EHR) system.